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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920233
Report Date: 03/03/2025
Date Signed: 03/03/2025 09:42:10 AM

Document Has Been Signed on 03/03/2025 09:42 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:MY PLACEFACILITY NUMBER:
315920233
ADMINISTRATOR/
DIRECTOR:
PETERS, VANLAFACILITY TYPE:
740
ADDRESS:6185 GARLAND WAYTELEPHONE:
(916) 409-5099
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
03/03/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Vanla Peter, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility and met with Administrator, Vanla Peters, to conduct a Pre- Licensing visit. The facility has a fire clearance for six (6) non-ambulatory residents. Administrator has an active certificate (#7027076740 with expiration date 12/01/2025).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and one (1) bathroom for resident use. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 116.4 degrees F. LPA observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit and fire extinguishers are maintained and ready for emergency use.

Garage area has been reconstructed into a three (3) bedrooms (two resident rooms and one staff room). The Fire Department has re-inspected and has approved renovations to garage space. LPA inspected garage reconstruction which is now equipped for two (2) resident rooms and one (1) staff room. Current facility sketch now matches the facility building layout.

Component III was completed with Licensee on Feruary 11,2025. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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