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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700182
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:04:29 PM


Document Has Been Signed on 04/08/2022 03:04 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: 6DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonathan SohaniTIME COMPLETED:
11:00 AM
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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 4/8/22 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 advisory was issued.

Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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