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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002969
Report Date: 12/20/2024
Date Signed: 12/20/2024 01:56:35 PM

Document Has Been Signed on 12/20/2024 01:56 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:EZE CAREHOMEFACILITY NUMBER:
345002969
ADMINISTRATOR/
DIRECTOR:		NINOBLA, ROJEL DANFACILITY TYPE:
740
ADDRESS:1123 NEWPORT WAYTELEPHONE:
(650) 307-2090
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:36 PM
MET WITH:Rojel NinoblaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On December 20, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the inspection tool. LPA met with Administrator and explained the purpose of the visit.

Today's census is six residents in care with no residents on hospice services. Facility is licensed for six non-ambulatory with hospice waiver of six.

During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: five residents bedrooms, three bathrooms, kitchen, backyard, staff room and the common areas. LPA observed audio alerts present on the front door, but with the back door it was not operating. LPA observed sharps, toxins and medications to be locked and secured. LPA observed facility to have ample supply of personal protective equipment (PPE's).

Pantry and Refrigerator were inspected and observed the presence of two days of perishable and seven days of non perishable food. LPA observed the exterior of the facility to be free from dangerous weapons and free of obstruction.

File review conducted for six resident records and two personnel records. Resident records are observed to be completed. LPA observed the two personnel records to have the required documents and are Administrators. LPA reviewed the Emergency Disaster Plan to be reviewed by Administrator on November 1, 2024. LPA observed documentation of Fire Drill conducted six separate occasion for the year of 2024.

LPA observed a copy of facility liability insurance. Annual Inspection tool completed and observed the facility to be in compliance to Title 22. No deficiencies cited.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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