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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 10/01/2024
Date Signed: 10/14/2024 08:30:47 AM

Document Has Been Signed on 10/14/2024 08:30 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/
DIRECTOR:		LIM, KARENFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRTELEPHONE:
(808) 228-0588
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 3DATE:
10/01/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Karen Lim and Aleksandr SheludchenkoTIME VISIT/
INSPECTION COMPLETED:
08:45 AM
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On 10/1/2024 an office meeting was held via Microsoft Teams to discuss the facility's pending change of ownership. Licensing Program Manager (LPM) Anthony Perez and Licensing Program Analyst (LPA) Cassie Yang met with Licensee Karen Lim, and Applicant/potential new licensee Aleksandr Sheludchenko.

Applicant informed LPA and LPM that he was not aware of the regulation in regards to unable to advertise pending facility name. It was discussed Licensee does not have control of property but Applicant does as he is the landlord. Licensee understands that she must obtain a lease back agreement until the pending application is approved.

Additionally, Licensee stated Applicant is now the Administrator of the facility. Licensee is aware that a copy of active Administrator Certificate needs to be provided to CCLD to appoint new Administrator.

LPA will forward a copy of this report to Licensee to review report, sign, and return a signed copy to CCL.

Exit interview conducted.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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