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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701084
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:42:09 AM

Document Has Been Signed on 06/29/2022 11:42 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:R & E SENIOR CARE, INC.FACILITY NUMBER:
342701084
ADMINISTRATOR:EMILY PASCUAFACILITY TYPE:
740
ADDRESS:5231 OLIVEHURST WAYTELEPHONE:
(916) 895-4357
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 2DATE:
06/29/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emily PascuaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived announced on 6/29/22 at 9:30am to review documents that are in need of updating in the Community Care Licensing Regional Office.


LPA met with Emily Pascua and Randmelvin Pozon, Licensee(s) to review the hospice waiver request documents to be submitted, and facility file documents to be updated to include the LIC 200 application, LIC308 Designation, LIC500 Personnel Log.



Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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