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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700182
Report Date: 12/16/2021
Date Signed: 12/16/2021 03:43:13 PM

Document Has Been Signed on 12/16/2021 03:43 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:KING OF HEARTS ELDERCAREFACILITY NUMBER:
092700182
ADMINISTRATOR:SOHANI, JONATHANFACILITY TYPE:
740
ADDRESS:3336 COUNTY CLUB DRIVETELEPHONE:
(530) 556-6544
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY: 6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jonathan SohaniTIME COMPLETED:
12:30 PM
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Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Jonathan Sohani.

A review of staff records on 12/16/21 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies. However, 1 technical advisories were issued.

Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
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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