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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001747
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:41:52 PM


Document Has Been Signed on 01/31/2024 02:41 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:SHAVLOVSKY, YANAFACILITY TYPE:
740
ADDRESS:5877 KING ROADTELEPHONE:
(916) 660-9947
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 3DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lisa ShitovaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday January 31, 2024 to conduct the unannounced annual inspection.

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

LPA Parks and Licensee Lisa toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, garage, 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.

LPA obtained updated copies of LIC610E and LIC500.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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