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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920217
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:00:39 AM

Document Has Been Signed on 11/14/2024 11:00 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:TWELVE BRIDGES RESIDENCE LLCFACILITY NUMBER:
315920217
ADMINISTRATOR/
DIRECTOR:		TULLGREN, DIANAFACILITY TYPE:
740
ADDRESS:409 CONFEDERATION CTTELEPHONE:
(916) 396-4189
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 0DATE:
11/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Diana TullgrenTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived on Thursday November 14, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. All files contained the required paperwork. This facility has a fire clearance for 6 (six) nonambulatory, of which 2 (two) can be on hospice and 1 (one) bedridden. Facility has all required postings in the hallway.

LPAs toured the facility with the administrator. The following areas were inspected for compliance: kitchen, backyard, resident bedrooms, bathrooms, and common areas. Facility has current fire extinguisher and a full first aid kit. Medications will be kept locked in a cabinet in the hallway. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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