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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701627
Report Date: 10/10/2025
Date Signed: 10/10/2025 02:21:26 PM

Document Has Been Signed on 10/10/2025 02:21 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:AZALEA LANEFACILITY NUMBER:
342701627
ADMINISTRATOR/
DIRECTOR:		SILAPAN, MONALISAFACILITY TYPE:
740
ADDRESS:8781 KELSEY DR.TELEPHONE:
(916) 667-8619
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
10/10/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Monalisa SilapanTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/10/25, at 11:00am, Licensing Program Analyst (LPA), Sommer Hayes conducted an announced inspection to the above facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 2/19/25, for an Initial license for a Residential Care Facility for the Elderly (RCFE). The requested capacity is for 6 non-ambulatory residents. LPA was greeted and accompanied on inspection by the applicant, Monalisa Silapan and Nina Menez.

This home is a single-story house located in a residential neighborhood. The home has 4 bedrooms. Bedroom #1 is currently a double occupancy bedroom with a master bath and cleared for non-ambulatory residents. Bedroom # 2 is currently a double occupancy for residents and cleared for non-ambulatory. Bedroom # 3 is a single occupancy room cleared for a non-ambulatory resident. Bedroom # 4 is a single occupancy room cleared for a non-ambulatory resident. There is a total of 2 bathrooms. Resident bedrooms are located on the left and right sides of the house.

In the outdoor area there was a sun room leading to the backyard, a covered patio with outdoor furniture, fruit trees and a Zen Garden. Outdoor passageways, walkways, driveways, and steps are free from obstructions. Fence and gates are in good repair. No swimming pools/bodies of water at this time.

{Con't on LIC809-C}

There is 1 refrigerator in the kitchen. Washer and dryer are located in a locked laundry room.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AZALEA LANE
FACILITY NUMBER: 342701627
VISIT DATE: 10/10/2025
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First aid kits were inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen area, available for staff use but inaccessible to residents. Centrally stored medications will be locked in two cabinets in kitchen.

Pre-licensing is not complete at this time.
LPA Hayes will return at another time when the following advisories are completed by the applicant, Monalisa Silapan.

Room #2 is approved by the Cosumnes Fire for a non-ambulatory room but is not approved by LPA Hayes for two non-ambulatory residents. This room is not appropriate for two non-ambulatory residents, two dressers, two night stands and two chairs and any assistive devices. There is not enough space to safely accommodate two residents in this space.
Applicant Monalisa Silapan has agreed to change this room into a single occupancy room from a double occupancy room.
Bathroom #2 Applicant will add vent cover to missing bathroom vent. Room #4 Remove extra furniture in this bedroom to avoid bed from blocking exit door.
Make sure backyard water hose is properly stored to avoid tripping hazards.

Make sure there is no one living in the house. Personal items need to be removed from the house before the next inspection.

Applicant Monalisa Silapan will follow up with River City Fire to add appropriate tags and inspections for both fire extinguishers to make sure they are properly charged and ready for the next inspection.

Based on a review of this home during this Pre-licensing visit, it was determined that this facility was found not to be in compliance at this time. LPA Hayes will coordinate an announced visit with applicant, Monalisa Silapan. LPA Hayes will notify the Central Application Bureau (CAB) that the pre-licensing and Component III has not been completed and not passed.

An exit interview was conducted, and a copy of this report has been provided to the applicant Monalisa Silapan.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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