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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701039
Report Date: 09/24/2024
Date Signed: 09/24/2024 09:16:08 PM


Document Has Been Signed on 09/24/2024 09:16 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: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: 4DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator Angelita Dayloan TIME COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an one year annual/required inspection. LPA Lund met with Administrator Angelita Dayloan and explained the reason for the visit. Census: 4

LPA Lund & Administrator Angelita Dayloan toured/inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Fire extinguishers (1/18/2024) and smoke detectors are current and in compliance with fire safety. LPA has the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Lund reviewed two staff & two resident files and were in compliance.

No deficiencies cited during today's inspection. An exit interview and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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