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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701167
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:56:15 PM


Document Has Been Signed on 07/26/2023 02:56 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:YOUNG AT HEART RCFE NO.1, INC.FACILITY NUMBER:
342701167
ADMINISTRATOR:MOLINYAWE, GLENDAFACILITY TYPE:
740
ADDRESS:9027 COLOMBARD WAYTELEPHONE:
(916) 689-7378
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Glenda MolinyaweTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual inspection on 07/26/2023 at 1:30 PM. LPAs met with Glenda Molinyawe and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for five non-ambulatory residents and has a hospice waiver for two. There are currently 6 residents who reside at this facility.

LPAs toured the facility with Glenda Molinyawe on 07/26/2023 at 2:00 PM.

LPAs reviewed 5 resident files and 3 staff files. All files were complete and maintained. LPAs reviewed 2 Medication Administration Records, which were complete and maintained. The facility has a first aid kit. The facility fire extinguisher, carbon detectors, and smoke detectors were in good repair. The facility had an adequate food supply, and the kitchen was sanitary and clean. The laundry room was sanitary and all toxins were locked. The residents rooms and bathrooms were clean and sanitary. In addition, all the required postings were posted throughout the facility. The exterior of the facility was clear of debris, and the emergency exit gate was in good repair.

As a result, of this annual visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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