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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920179
Report Date: 10/09/2024
Date Signed: 10/15/2024 09:34:42 AM

Document Has Been Signed on 10/15/2024 09:34 AM - 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:NEW DEVOTION FAMILY CARE HOME LLCFACILITY NUMBER:
315920179
ADMINISTRATOR/
DIRECTOR:		BLAS, MEKISHAFACILITY TYPE:
735
ADDRESS:572 SILVER CLOUD CT.TELEPHONE:
(863) 205-4134
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 0DATE:
10/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Shawnette Etheridge, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with Licensee Shawnette Etheridge during today's inspection. Currently there are no clients in care.

Facility was inspected both indoors and outdoors. LPA inspected 4 client bedrooms, 2 bathrooms, common living areas, kitchen, staff area and outdoor areas. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in cabinet near the kitchen and dining room area. LPA inspected client bedrooms and the bedroom had appropriate furnishings, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Smoke detectors and carbon monoxide detectors were checked. Fire clearance was granted on 06/25/24 for 4 ambulatory clients. Kitchen is clean, sanitary, and in good repair. A working telephone present for residents use once licensed.

Licensee agrees to notify LPA once first consumer is admitted. COMP III training was provided to licensee. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted. Copy of report provided to licensee.

**THIS IS AN AMENDED DOCUMENT-AMENDED ON 10/15/2024.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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