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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:27:30 PM


Document Has Been Signed on 05/02/2024 03:27 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LOVE AND COMFORT ELDERLY CAREFACILITY NUMBER:
342700731
ADMINISTRATOR:SHARP, KAYDIAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cleopatra GardinerTIME COMPLETED:
04:00 PM
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On 5/2/24 at 3:00pm, Licensing Program Analyst, (LPA) Kevin Gould conducted an unannounced Case Management inspection to request additional documents to approve newly appointed administrator.

LPA request the following fully completed documents: Completed LIC 200 form (Facility Application) identifying the newly appointed administrator. The department also requests a fully completed LIC 501 (LPA noted missing items in the LIC 501 including social security number). The department also requests a copy of the newly appointed administrator's administrator certificate.

The department will not be able to confirm the new administrator until all documents are provided to the department.

exit interview conducted and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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