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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002951
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:24:39 PM


Document Has Been Signed on 06/20/2024 12:24 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:LIVING WATER CARE HOME INC, THEFACILITY NUMBER:
345002951
ADMINISTRATOR:PRANOTO, HERLINAFACILITY TYPE:
740
ADDRESS:7800 CLAYPOOL WAYTELEPHONE:
(279) 529-2233
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lina Pranato, AdministratorTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Herlina "Lina" Pranato, Administrator, who contacted Licensee, Grace Gunawan, by phone, to notify her of the inspection. Also present was Lili Kurniawati Oey, caregiver. LPA observed (3) residents in the common area watching television and (1) resident in their room.

LPA spoke to Licensee by phone and discussed the notification that was sent to LPA yesterday regarding an upcoming change in ownership. LPA confirmed that the pending Licensee is aware a new application must be submitted to obtain a new license. LPA also discussed how the current Licensee remains responsible for the facility until the new license is issued. LPA stated the letter to be given to residents and their responsible persons should have the actual date when it is issued. LPA also stated how the letter should indicate that residents are being given at least (60) days notice in writing, per regulation. LPA requested an updated copy of the letter be provided to the Department (via LPA) once the letter is issued.

Licensee acknowledged all points discussed and agreed to provide an updated copy of the letter.

LPA and the Administrator toured the interior of the facility. LPA observed (4) residents present. LPA observed all rooms to be clean and tidy. There is sufficient food on site, including fresh produce, and the sharps and toxins are locked in the kitchen. Fire Extinguisher was last serviced 3/27/24.

There are no deficiencies issued in today's report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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