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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:32:16 AM


Document Has Been Signed on 10/03/2023 11:32 AM - 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 LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
10/03/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Misivono QadrokaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced in order to conduct a collateral visit. LPA Moleski met with staff member Misivono Qadroka and explained the purpose of the visit. LPA Moleski called facility administrator Salote Lewis and left a voicemail explaining the purpose of the visit.

LPA Moleski attempted to interview a resident (R1), but R1 was not present. LPA Moleski received a telephone number for R1. LPA Moleski reviewed R1's file.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Qadroka.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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