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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701436
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:20:57 PM

Document Has Been Signed on 11/08/2024 02:20 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RANCHO RESIDENTIALFACILITY NUMBER:
342701436
ADMINISTRATOR/
DIRECTOR:		MENDOZA AILEEN MAEFACILITY TYPE:
740
ADDRESS:12057 ALERIATELEPHONE:
(916) 619-7896
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 6CENSUS: 0DATE:
11/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:37 PM
MET WITH:Tony Hoang and Aileen MendozaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/8/24, at 1:30pm, Licensing Program Analyst (LPA), Arvin Villanueva conducted an announced inspection to the above facility for purpose of continuing their pre-licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 3/22/24, for an Initial license for a Residential Care for the Elderly. The requested capacity is for 6 residents.

LPA met the applicants, Tony Hoang and Aileen Mendoza and explained the purpose of the visit.

LPA and Applicants conducted tour of the facility. All bedrooms are now fully furnished with beds, bedside table, lamp and spacious storage to accommodate resident belongings.

Personal Rights and Complaint Poster were observed to be posted at the kitchen/livingroom area.

LPA also reviewed application documents.

LPA conducted component III orientation with the applicants, Tony Hoang and Aileen Mendoza.

Pre-Licensing is now complete. No objections were made to licensure.

Exit interview was held with applicants, and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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