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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701039
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:51:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A GOLDEN DOVEFACILITY NUMBER:
342701039
ADMINISTRATOR:PUA, ARCELYFACILITY TYPE:
740
ADDRESS:3339 GLENMOOR DR.TELEPHONE:
(916) 541-1534
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:6CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Arcely PuaTIME COMPLETED:
01:00 PM
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On 8/20/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted a pre-licensing inspection for A Golden Dove (RCFE). LPA Gould met with Administrator Arcely Pua and together conducted the inspection.

The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, up to six (6) may be non-ambulatory.

LPA Gould conducted a tour of the home to ensure the corrections needed, identified during the pre-licensing inspection on 7/30/21. LPA observed that all corrections have been made to the physical plant.
  1. Ensure all light fixtures have appropriate light bulbs and are operational. - Corrected
  2. Remove fridge and broken chair from bedroom #1. - Corrected
  3. sheets and linen for the bed in Bedroom #1 - Corrected
  4. repair kitchen range so it will light when knobs are turned on. - Corrected
  5. Remove all hazards from the back yard including but not limited to removing the freezer or making it operational, remove frayed tarp over awning, remove any excess wood, metal debris from the back yard. - Corrected
  6. ensure all landscaping is complete, LPA observed a large pile of rocks to be used for landscaping in the front driveway - Corrected
  7. Ensure the sliding closet door in bedroom #2 is operational - Corrected
  8. ensure broken dresser handle is fixed in bedroom #5 - Corrected

At the time of inspection, facility is in compliance with all title 22 regulations. LPA will schedule Component 3 with the Licensee to be completed the following week. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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