<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700678
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:43:28 PM


Document Has Been Signed on 01/26/2024 03:43 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:LOVING CARE SENIOR LIVING IIFACILITY NUMBER:
342700678
ADMINISTRATOR:RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:4021 FAIRWOOD WAYTELEPHONE:
(916) 944-4969
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kelly ConleyTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a require annual inspection utilizing the care tool. LPA met with house manager, Kelly Conley, and explained the purpose of the visit.

During today's visit, LPA and House Manager conducted a tour of the facility. Areas toured included but limited to: private resident rooms, bathrooms, kitchen and common areas. LPA observed four residents present in the common areas and two residents to be resting in their bedrooms.

LPA observed the facility to have 2+ days of perishable and 7+ days on nonperishable foods. LPA observed medications, sharps and toxins to be locked and secured. LPA observed the facility to have adequate supply of linen and personal protective equipment.

LPA and House Manager completed the full care tool and found the facility to be in compliance.

No deficiencies cited.

At this time, LPA is requesting a copy of LIC 500 and facility liability insurance to be emailed to LPA Yang by Monday February 5.

Exit interview and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1