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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701320
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:30:58 PM

Document Has Been Signed on 01/19/2024 03:30 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:CASA LORENZOFACILITY NUMBER:
342701320
ADMINISTRATOR:SUN, LEE ABRAHAMFACILITY TYPE:
735
ADDRESS:10149 BRIAN KELLY WAYTELEPHONE:
(916) 829-5533
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 0DATE:
01/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lee Abraham SunTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived announced to the facility to conduct a pre-licensing inspection. LPA met with Licensee/Administrator Lee Abraham Sun and Co-licensee Jehan Sun, and explained the purpose of the visit.

The facility has a fire clearance to serve 4 individuals, of which 3 may be considered ambulatory and 1 may be considered non-ambulatory. The resident considered non-ambulatory may only reside in bedroom labeled "D" on the facility sketch. LPA Valerio observed 0 residents in care. The facility is a one story home with four (4) bedrooms, two (2) restrooms, a dinning area, a living room area, a kitchen area, a laundry area, garage area, and an exterior area. The residents will have access to all areas of the home.

LPA observed all resident bedrooms to have a bed, night stand, lamp, chair, dresser, closet space, and the ability to lock the door with a key. Restrooms were observed to be clean, organized, and fully stocked with toilet paper, paper towels, soap, and hand sanitizer. Common areas, including the dinning area, living room, and hallway, were observed to be fully furnished and clean. LPA observed the areas where cleaning supplies, toxins, knives, and sharps will be locked and inaccessible to residents in care. LPA observed the areas where food and emergency supplies of food/water will be held. The facility has emergency supply backpacks for each resident and supplies for the home readily available. LPA observed the fire extinguisher, carbon monoxide detector, and heating/air condition to be in working condition. The exterior area was observed to have a large area to conduct outdoor activities and/or visitation. Emergency walk ways were free from obstructions.

Licensee/Administrator was made aware that the pre-licensing inspection has been completed and there are no deficiencies. Component III was completed during the visit and there were no further questions. LPA will inform the Regional Office and the CAB Analyst of the results of the inspection. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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