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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 10/19/2023
Date Signed: 10/19/2023 10:43:07 AM


Document Has Been Signed on 10/19/2023 10:43 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 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:
10/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carlo Mariano and Karen LimTIME COMPLETED:
11:15 AM
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On 10/19/2023, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced to conduct a proof of correction visit. LPAs met with caregiver who contacted administrator who arrived to the facility shortly afterwards.

LPAs and Administrator conducted a tour of the facility to ensure the healthy and safety of the Residents in care. LPAs and Administrator discussed the citation that was cited on 10/11/2023 with Plan of Correction due 10/12/2023. LPAs informed Administrator Plan of Correction has yet to be received. Administrator informed LPAs that the LIC809D was overlooked when she was reading the reports. LPAs reminded Administrator failure to correct may assess $100 per day until Plan of Correction is received.

During today's visit, Administrator provided proof of correction. Civil penalty 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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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