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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 09/05/2023
Date Signed: 09/05/2023 02:37:56 PM


Document Has Been Signed on 09/05/2023 02:37 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:ONLY LOVE ELDERLY CARE HOMEFACILITY NUMBER:
345002979
ADMINISTRATOR:LIM, KARENFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRTELEPHONE:
(808) 228-0588
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 3DATE:
09/05/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Karen LimTIME COMPLETED:
02:30 PM
NARRATIVE
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An office meeting was held at the Sacramento North Regional Office at 9835 Goethe Road, Suite 100. Licensing Program Analysts (LPA's) Cassie Yang and Cheyenne Ratajczak and Licensing Program Manager (LPM) Troy Ordonez met with Licensee, Karen Lim, regarding the plan of correction for deficiencies cited on Friday September 1, 2023.

Licensee reported to the Department that all staff has been paid for the period of August 1-15, on Saturday September 2, 2023. LPA informed Licensee that no updates was provided by Licensee until date of meeting. Licensee explained she wanted a meeting in-person to clarify on the updates.

Licensee stated no change of Administrator will be made at this time as she previosuly stated on FRiday, September 1, 2023. Licensee stated she will comply with Reporting Requirements if and/or when she does change Administrator.

As a result of today's meeting, a civil penalty was assessed.

Exit interview,and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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