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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920211
Report Date: 10/01/2024
Date Signed: 10/02/2024 08:33:25 AM

Document Has Been Signed on 10/02/2024 08:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MILLPORT VILLASFACILITY NUMBER:
315920211
ADMINISTRATOR/
DIRECTOR:		AREFA, NEGASHFACILITY TYPE:
740
ADDRESS:7641 MILLPORT DRIVETELEPHONE:
(916) 472-6669
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 1DATE:
10/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Negash ArefaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/1/24 to conduct a Prelicensing Inspection utilizing the CARE tool. LPA Met with the licensee.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA, reviewed a resident file . File is complete and well organized. Applicant will follow guidance for files in LIC 311F

Staff file was reviewed. File is complete and organized.

Component III was completed.

No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance.

License is pending.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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