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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920216
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:38:34 PM

Document Has Been Signed on 02/21/2025 03:38 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:ROSE ARBOR VILLAGEFACILITY NUMBER:
345920216
ADMINISTRATOR/
DIRECTOR:		EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 108CENSUS: 39DATE:
02/21/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Antonette Edwards, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Antonette Edwards, to follow-up regarding a plan of correction issued on February 13th, 2025 and due on February 14th, 2025.

During inspection, LPA reviewed plan received by the Department on February 14th, 2025 to address staff services for residents' needs, including oversight of care being provided to residents and oversight for response times to call buttons. LPA cleared deficiency at the conclusion of this visit.

No deficiencies are being cited as a result of today's inspection. Exit interview was conducted. Signature on on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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