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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700070
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:11:33 PM


Document Has Been Signed on 10/30/2023 02:11 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:KIND CONNECTIONFACILITY NUMBER:
342700070
ADMINISTRATOR:DELA PAZ, MA. LOURDESFACILITY TYPE:
740
ADDRESS:8159 WACHTEL WAYTELEPHONE:
(916) 599-0477
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Lourdes Dela PazTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday October 30, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed client (4) and staff (4) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training (initial and ongoing). Facility has supply of PPE including shields, N95s, gowns, gloves, and covid tests. Facility is clean, organized, and well maintained.

LPA Parks and Administrator Lourdes toured the facility together to ensure the health and safety of residents in care. The areas toured included bedrooms, bathrooms, kitchen, common areas, garage, and backyard. In the areas toured, there were no health or safety violations observed.

LPA obtained a copy of current liability insurance and LIC500.

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: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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