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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:38:00 PM


Document Has Been Signed on 12/13/2023 03:38 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR:FAAMAUSILI,CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
12/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Que-Anna Richards, CaregiverTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Caregiver, Que-Anna Richards, to follow-up on plan of corrections made to the facility on 10/30/2023 to be completed on 10/31/2023 and 11/30/2023. Administrator, Chris Faamausili, gave permission to have caregiver sign report.

During today's visit, LPA took the temperature of the water and found temperature to be 116 degrees F. LPA observed that fire extinguisher was serviced and carbon monoxide detector was installed and operable. LPA observed carpets to be cleaned, trash compacter to be removed, backyard gate repaired, locks on drawers repaired, and the ability to provide ice to the residents.

LPA cleared deficiencies during visit.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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