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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701039
Report Date: 08/24/2021
Date Signed: 08/31/2021 03:24:22 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:
08/24/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Licensee, Ronald PuaTIME COMPLETED:
04:30 PM
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On 8/24/21 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Licensee Ronald Pua. LPA Gould and Licensee went over the component 3 powerepoint.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, Health Related Services and Conditions and Dementia Care.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted. Once approved, a copy of the license will be set to the Licensee.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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