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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002941
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:30:27 PM


Document Has Been Signed on 03/11/2024 03:30 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:KOTA CAREFACILITY NUMBER:
315002941
ADMINISTRATOR:SHANE STUMPFFACILITY TYPE:
740
ADDRESS:1652 MARKDALE LANETELEPHONE:
(530) 379-6708
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 3DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday March 11, 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 (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and Administrator Shane 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. All required posting were observed.

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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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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