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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002902
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:49:57 PM


Document Has Been Signed on 03/07/2024 01:49 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:UNITY MEMORY HOME CAREFACILITY NUMBER:
345002902
ADMINISTRATOR:LIU, YINGFACILITY TYPE:
740
ADDRESS:8161 CHIMANGO COURTTELEPHONE:
(916) 301-8792
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator- Ruby LiuTIME COMPLETED:
02:00 PM
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On 03/07/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 02/15/24 for complaint Control Number 25-AS-20231128082121. LPA met with Administrator, Ruby Liu, and explained the purpose of the visit.

LPA explained to Administrator that failure to correct plan of correction by the given due date could and will result to $100 per day until corrected civil penalty.

During today's visit, Administrator informed LPA that they will submit the POC by the end of the day

ยท CCR 87468.1(a)(3) and 87468.1(a) (15) 87468.1 Personal Rights of Residents in All Facilities

As a result of today's inspection, civil penalties were assessed.

Exit interview conducted and a copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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