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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920094
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:17:46 PM


Document Has Been Signed on 05/21/2024 01:17 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:LOVE YOU DAD 2 INCFACILITY NUMBER:
315920094
ADMINISTRATOR:TIMOFEY. ILONAFACILITY TYPE:
740
ADDRESS:6200 SWEETGRASS COURTTELEPHONE:
(916) 899-6537
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Ilona TimofeyTIME COMPLETED:
01:30 PM
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LPA Parks arrived on Tuesday May 21, 2024 to conduct a case management visit. LPA met with Administrator Ilona and explained the purpose of the visit.

This is a follow up visit for a non-hospice death that occurred on 5/14/2024 and submitted to the Department on 5/15/2024.

During today's visit, LPA interviewed staff regarding their observations of R1. LPA obtained and reviewed the following documents: LIC601, DNR, LIC602, and LIC625.

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

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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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