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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700984
Report Date: 06/21/2022
Date Signed: 06/21/2022 03:22:27 PM


Document Has Been Signed on 06/21/2022 03:22 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SYCAMORE RESIDENTIAL CARE CENTER, B LLCFACILITY NUMBER:
342700984
ADMINISTRATOR:NASSAR, NADERFACILITY TYPE:
740
ADDRESS:4545 SYCAMORE AVENUE, UNIT BTELEPHONE:
(916) 595-9991
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Karen Bowers, Residential CoordinatorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 6/21/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Residential Coordinator, Karen Bowers, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of the residents in care. Areas toured include but are not limited to: 6 bedrooms and 3 bathrooms for residents, common area, dining room, food supply, office, laundry room, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Residential Coordinator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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