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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001541
Report Date: 05/10/2023
Date Signed: 05/10/2023 11:43:49 AM


Document Has Been Signed on 05/10/2023 11:43 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:CANA PLACE 2FACILITY NUMBER:
317001541
ADMINISTRATOR:SAMUEL LEEFACILITY TYPE:
740
ADDRESS:6845 PARK PLACETELEPHONE:
(916) 797-0714
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Samuel LeeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 10, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (5) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training. Staff have current first aid and CPR training.

LPA Parks and Administrator Samuel toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. Water temperatures in kitchen and bathrooms were within the required range of temperatures. In the areas toured, there were no health or safety violations observed.

LPA obtained updated copy of LIC500 and current liability insurance. LPA is requesting updated copy of the LIC610E,

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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