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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:40:32 PM


Document Has Been Signed on 06/21/2023 03:40 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:SACRAMENTO SENIOR LIVINGFACILITY NUMBER:
342701230
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:6825 BENDER CTTELEPHONE:
(510) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:6CENSUS: 0DATE:
06/21/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Salote LewisTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a prelicensing inspection at this home. LPA Moleski met with Salote Lewis and explained the purpose of the visit.

LPA Moleski reviewed Lewis's application documents, fire clearance and floor plan. The home is cleared for six non-ambulatory residents. Lewis's administrator certificate number is 6062098740 and it expires 8/8/24.

LPA Moleski toured the home with Lewis and inspected common areas, kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested and measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet in a caregiver room for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski conducted Component III Orientation with Lewis.

No deficiencies were observed during this visit. Prelicensing is complete for this applicant. An exit interview was conducted and a copy of this report was left with Lewis.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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