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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700167
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:40:36 PM

Document Has Been Signed on 02/06/2025 12:40 PM - 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:ALDER GROVE SENIOR LIVING IIFACILITY NUMBER:
342700167
ADMINISTRATOR/
DIRECTOR:
TAN, CLIFFORDFACILITY TYPE:
740
ADDRESS:637 SHOCKLEY ROADTELEPHONE:
(650) 281-6612
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Clifford Tan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 2/6/2025 LPA Tryon visited the licensee's private home, where 4 of the residents from Alder Grove Senior Living II are staying temporarily. LPA toured the house. The house has 4 bedrooms/2 bathrooms, a large kitchen with 2 refrigerators and plenty of cabinets/cupboards. There are cleaners under the sink in hall bathroom. Mr. Tan assured LPA that the handyman is coming this afternoon to place locks where needed such as under sink cabinets in bathrooms and kitchen, potentially hazardous items, etc.
Bedrooms are spacious. 2 of the rooms currently have large beds, which will be replaced by smaller beds if the decision is made to apply for a license for this house, as the space is a little tight right now, but would be fine with smaller beds.
There is a hot tub currently on the back patio, which Mr. Tan said will be removed if application is pursued. There is currently no water inside, and a cover over it. Also, the back yard slopes off at maybe a 45 degree angle at the back; a fence would need to be constructed
There is plenty of food in the house, furnishings are appropriate, etc.

Mr. Tan is meeting with the fire department this afternoon to have them do a pre-inspection of his house to see if it is feasible to convert it to a care home.

LPA spoke with 2 verbal residents who were available. Both said they are doing well, staff is taking good care of them; the staff got them out of the care home quickly during the fire and it went well. They told me they are okay with the situation, and they wish to stay with Mr. Tan.

Mr. Tan will contact CCL as soon as he learns what the fire department says; and with the decision to go forward with an application for this home or not.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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