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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002941
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:16:47 PM


Document Has Been Signed on 03/10/2023 04:16 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:KOTA CAREFACILITY NUMBER:
315002941
ADMINISTRATOR:SAPKOTA, AMRITAFACILITY TYPE:
740
ADDRESS:1652 MARKDALE LANETELEPHONE:
(530) 379-6708
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 0DATE:
03/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Amrita SapkotaTIME COMPLETED:
04:30 PM
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On Friday March 10, 2023, Licensing Program Analyst Melissa Parks arrived to conduct a prelicensing inspection. Due to Covid-19 precautions, LPA wore N95 respirator upon entering the property. LPA was greeted with Administrator Amrita and allowed entry into the facility.

LPA toured the facility with Administrator Amrita. This facility has a fire clearance for 5 non-ambulatory residents and 1 bedridden resident. There are 4 resident bedrooms and 2 bathrooms. Water temperatures were within the required range. Showers have required nonskid mats. Kitchen is clean and organized. All knives and sharp objects are kept inaccessible to clients. All appliances in the kitchen are observed to be clean and operational. Toxins and cleaning supplies are to be kept in the garage. Medications will be kept locked in hallway cabinets. Washer and dryer are in a separate room by the garage and are clean and noted to be operational. Backyard was clear of debris and hazards.

Administrator tested fire alarms and are in working order. Facility has one fire extinguishers which was recently purchased. Facility has a fully stocked first aid kit.

Component III has been completed at this time with Administrator Amrita.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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