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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001747
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:07:01 PM

Document Has Been Signed on 01/23/2025 02:07 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:KING ROAD CARE HOMEFACILITY NUMBER:
315001747
ADMINISTRATOR/
DIRECTOR:
SHAVLOVSKY, YANAFACILITY TYPE:
740
ADDRESS:5877 KING ROADTELEPHONE:
(916) 660-9947
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:SHITOVA, LARISATIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analysts (LPA) Kerry Hiratsuka and Kayla Adkison arrived on January 23, 2025 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed 2 resident and 3 staff files. All resident files contained the required paperwork. All staff files contained the required paperwork.

LPAs and Licensee Larisa toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, and backyard. In the areas toured, there were no health or safety violations observed.

Facility was clean and well organized. Facility was current on fire drills. All required posting were observed.

No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.
Troy OrdonezTELEPHONE: (916) 263-4700
Kerry HiratsukaTELEPHONE: (916) 591-0210
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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