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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701146
Report Date: 05/08/2023
Date Signed: 05/08/2023 02:03:08 PM


Document Has Been Signed on 05/08/2023 02:03 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:HOMECARE EL SHAMAHFACILITY NUMBER:
342701146
ADMINISTRATOR:NAWASA, APAKUKIFACILITY TYPE:
740
ADDRESS:4991 44TH STREETTELEPHONE:
(209) 688-7591
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:6CENSUS: 3DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Kuki NawasaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to conduct an annual inspection. Moleski and Richardson met with administrator Kuki Nawasa and explained the purpose of the visit.

Nawasa's administrator certificate number is 6028899740, and it expires on 06/05/2024.

Moleski and Richardson toured the facility with Nawasa and inspected common areas, kitchen, bedrooms, bathroom areas and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility's water temperature was tested and measured 105 degrees Fahrenheit. The facility temperature was 72 degrees, which is within the required range. Moleski and Richardson observed a first aid kit and working carbon/smoke detectors. Moleski and Richardson observed a minimum 2-day perishable supply and a 7-day supply of nonperishable food.

Moleski, Richardson and Nawasa reviewed MARs and other medical documents.

Residents were not available for interviews. Moleski and Richardson interviewed one staff member (S1). Items marked N/A on the CARE tool for this visit were addressed during the post-licensing visit conducted on 05/08/23. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Nawasa.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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