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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701407
Report Date: 06/11/2024
Date Signed: 06/11/2024 09:25:14 AM


Document Has Been Signed on 06/11/2024 09:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WHOLESOME ELDERLY ON TFACILITY NUMBER:
342701407
ADMINISTRATOR:ESTILLORE, NOELFACILITY TYPE:
740
ADDRESS:5332 T STREETTELEPHONE:
(916) 678-0268
CITY:SACRAMENTOSTATE: CAZIP CODE:
95819
CAPACITY:6CENSUS: 0DATE:
06/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Chris Faamausili TIME COMPLETED:
09:32 AM
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On 06/11/2024 at 8:29 AM, Licensing Program Analyst (LPA) Pang Lee arrived announced to conduct a Pre-Licensing Inspection follow-up of the facility to ensure compliance with Title 22 regulations. LPA Lee met with licensee, Chris Faamausili who assisted in today’s inspection.

Noel Estilore will be the administrator to this facility. Administrator certificate number # is 6033614740 and will expire on 02/09/2025. The facility has a fire clearance for 6 non-ambulatory residents to accept and retain at any given time. The facility will employ staff who are live-in caregivers. The facility will ensure that there is always at least one caregiver present in the facility at all times. There were no residents in care at this time. LPA Lee toured the facility with Chris and reviewed the updated facility sketch and the facility sketch aligned with the facility. During today's visit, all corrections were completed.

* Licensee/Administrator will ensure that an updated plan of operation to include live in staff- Completed, on 05/31/2024, licensee emailed LPA Lee an updated plan of operation to include live in staff and expectations.

· Licensee/Administrator will ensure that an updated facility sketch to include the four cameras in the home, the staircase closet, and the detached garage- Completed, on 05/31/2024, licensee emailed LPA Lee an updated facility sketch which reflected the four cameras in the home, the staircase closet and the detached garage. The up dated plan of operation also included the expectation of the cameras in the home.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407
VISIT DATE: 06/11/2024
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· Licensee/Administrator will ensure that the facility has sufficient supplies of hygiene for resident use- During today’s visit, LPA Lee observed sufficient supplies of hygiene for 6 residents in care.

· Licensee/Administrator will endure that the facility has sufficient 7 days of non-perishable food and 2 days perishable food at all times-During today visit, LPA Lee observed sufficient 7 days of non-perishable food and 2 days perishable food for residents in care.

· Licensee/Administrator will ensure that the facility has a first aid kit including a thermometer and a current first aid manual-During today’s visit, LPA Lee observed the facility had a complete first aid kit that contains the required components such as a thermometer and a current first aid manual.

· Licensee/Administrator will ensure that there are activity supplies and equipment made available for residents-During today’s visit, LPA Lee observed activity supplies such as board games, puzzles, books and cards made available to residents in care at this time.

· Licensee/Administrator will ensure that there is a rail install/place in the front porch to prevent residents from fall over-During today’s visit, LPA Lee observed a new rail installed in the front porch to ensure that all residents are safe from falling over the leveled porch.


Applicant was advised If any changes in plan of operation or to the facility they will need to submit the updated plan of operation and an updated facility sketch and informed the department which will also need to be reviewed and approved by the Department. Component III was completed at this time with the licensee Chris. The applicant has passed the pre-licensing component of the application process. LPA Lee will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report was provided to the licensee, Chris.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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