<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:40:14 AM


Document Has Been Signed on 12/15/2023 11:40 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: 4DATE:
12/15/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Licensee/Administrator- Karen LimTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/15/2023 at 11:00 AM, a hybrid Non-Compliance Conference meeting was held with Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100.

Present in the meeting was Administrator/Licensee, Karen Lim, LPM Anthony Perez, Licensing Program Analyst (LPA) Cheyenne Ratajczak and LPA Cassie Yang. Regional Manager (RM), Alycia Berryman, was present via Microsoft Teams Meeting.

Topics discussed during this meeting were:
  • Previous false claims/statements
  • Ensuring criminal clearance prior to employment
  • Ensuring Licensee obtain control of property
  • Reporting Requirement
  • Ensuring personnel and resident records are complete

The licensee was in agreement with the drafted non-compliance plan as outlined in LIC 9111.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1