342700984-6-15-2021-25-AS-KHIA-C3ZQG2-20210615120849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700984
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:09:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	SYCAMORE RESIDENTIAL CARE CENTER, B LLC		FACILITY NUMBER:	342700984
ADMINISTRATOR:	NASSAR, NADER		FACILITY TYPE:	740
ADDRESS:	4545 SYCAMORE AVENUE, UNIT B		TELEPHONE:	(916) 595-9991
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	6	CENSUS: 0	DATE:	06/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Raghda Nassar		TIME COMPLETED:	12:20 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) K. Hiratsuka, arrived at the facility announced on 06/15/2021 to conduct an announced prelicensing visit. LPA met with Facility Representatives Raghda and Nader Nassar, and explained the purpose of the visit. Mr. Nassar did have to leave during this visit and LPA finished the visit with Miss Nassar. Prior to initiating the prelicensing visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Raghda Nassar. This facility has a fire clearance for two ambulatory and four non-ambulatory residents. This facility has six private resident rooms. The main entrance has a ramp leading in. The front of this facility has two entrances; one with a ramp and one that does not. The main entrance opens to the main common area. The second door opens to a short hallway. The kitchen and dining area are located between the two doors. To the left of the main entrance there is a door leading to the four private non-ambulatory rooms, two full common bathrooms, exit to the outside, and laundry room. All four rooms have small patios. To the right of the main entrance is the kitchen and dining area and leads to a hallway that has the two ambulatory only resident rooms that have small patios, a full common bathroom, and office. All bathrooms have grab bars and nonskid mats.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SYCAMORE RESIDENTIAL CARE CENTER, B LLC	FACILITY NUMBER: 342700984
	VISIT DATE: 06/15/2021

NARRATIVE

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This facility shares a driveway with the building across the driveway. That building is separate address, but shares the lot.. The lot is surrounded by a fence that has a gate across the driveway and a pedestrian gate; however, the gates are not locked and shall remain unlocked at all times.

Component III orientation was completed.

This facility meets regulations. LPA is going to submit this report to the applications specialist.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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