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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700429
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:42:29 AM

Document Has Been Signed on 02/15/2024 11:42 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NEW LIFEFACILITY NUMBER:
342700429
ADMINISTRATOR:CUSTURA, VLADFACILITY TYPE:
740
ADDRESS:6307 GRANT AVETELEPHONE:
(916) 285-5302
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Vlad CusturaTIME COMPLETED:
11:45 AM
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On 2/15/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE tool. LPA met with Administrator, Vlad Custura, and explained the purpose of the visit.

LPA observed one resident sleeping in the common area, three residents resting in their private rooms, and one resident in the backyard.

During today's visit, LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six resident bedrooms, two bathrooms, kitchen, laundry room, backyard and the common areas. LPA observed toxins to be locked in the laundry room. LPA observed facility to be at a comfortable temperature of 74*. LPA observed fire extinguisher present, last serviced on 06/21/2023. LPA observed bathrooms to be clean with nonskid mats present. LPA observed facility to have 2+ day of perishable and 7+ days on nonperishable foods.

File review conducted for S1, S2, R1, R2 and R3. Administrator reported there are no residents on hospice services and no residents with pressure injuries.

LPA and Administrator discussed placing medical training verifications for S1 on file. CARE tool was completed with Administrator and found facility to be in compliance to Title 22.

LPA took a photo of facility liability insurance. At this time, LPA is requesting a copy of LIC 500 to be emailed to LPA by Tuesday February 20, 2024.

Exit interview conducted and a copy was emailed to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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