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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920093
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:00:32 PM

Document Has Been Signed on 04/08/2024 02:00 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:WELLNESS CARE HOMEFACILITY NUMBER:
315920093
ADMINISTRATOR/
DIRECTOR:		RAMOS, GRETCHENFACILITY TYPE:
740
ADDRESS:5536 GRAHAM COURTTELEPHONE:
(714) 350-2868
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 0DATE:
04/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Gretchen RamosTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday April 8, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. This facility has a fire clearance for 6 nonambulatory and a staff bedroom. Facility has all required postings in the hallway.

LPA toured the facility with Licensees Gretchen and Russell. The following areas were inspected for compliance: kitchen, backyard, resident apartments, resident bathrooms, staff bedroom and common areas. Facility has a current fire extinguisher and a full first aid kit. Medications will be kept locked in a closet in the hallway. Cleaning chemicals and knives/sharps will be kept locked and inaccessible to residents.

Component III has been completed at this time.

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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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