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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004613
Report Date: 12/16/2021
Date Signed: 12/16/2021 11:08:50 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/16/2021 11:08 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CROWN JEWEL VILLAFACILITY NUMBER:
347004613
ADMINISTRATOR:DASCALESCU, IONELFACILITY TYPE:
740
ADDRESS:5422 YDRA COURTTELEPHONE:
(916) 989-5511
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 0DATE:
12/16/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:LUMINITA DASCALESCUTIME COMPLETED:
10:57 AM
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On 12/15/21, LPA Kevin Mknelly conducted an annual inspection with licensee LUMINITA DASCALESCU.

The Facility type for the visit, due to technical issues, was not properly identified as an annual inspection as that option was not available at the time.

This report, dated 12/16/21, is to report is to properly record that the Annual Inspection visit was conducted, that there are currently no residents in care and that no health or safety issues were observed during the inspection.

See report dated 12/15/21 for further detail.

No deficiencies were issued as a result of the inspection.

This report was provided to the licensee by email, signature requested and will be maintained on file.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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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