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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 11/08/2023
Date Signed: 11/09/2023 08:44:39 AM


Document Has Been Signed on 11/09/2023 08:44 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:
11/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:CaregiverTIME COMPLETED:
04:00 PM
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On November 8, 2023 Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding a plan of correction the Department did not receive. LPA met with Caregiver, Carlo Mariano, who informed LPA Administrator is not at the facility. Caregiver contacted Administrator who LPA spoke with on the phone. LPA informed Administrator the purpose of the visit.

LPA discussed the LIC 809-D that was cited on 10/11/2023 with due date 10/27/2023 was not received. Administrator informed LPA it was submitted via fax although LIC 809-D stated to submit the documents via email to LPA. Administrator informed LPA she will resend the LIC 503's to LPA Yang via email as soon as possible as Administrator is not at the facility right now.

LPA informed Administrator to do so at earliest convenience and failure to do so may result to civil penalty as failure to correct.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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