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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 03/19/2024
Date Signed: 03/22/2024 09:56:57 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/22/2024 09:56 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: 5DATE:
03/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Karen LimTIME COMPLETED:
03:55 PM
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On 3/19/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management annual continuation visit. LPA met with Administrator, Karen Lim, and explained the purpose of the visit.

Today's census is five residents in care, three on hospice services. Facility is in compliance to licensure.

During today's visit, LPA and Administrator conducted a file review for four residents files, five staff files, Emergency Disaster Plan, and Facility Inflection Control. LPA observed resident files to be complete with the required documents. LPA observed personnel files to be completed with criminal background clearance.

LPA observed facility to be conducting quarterly fire drills documented. LPA informed Administrator to ensure list of resident participants are included and listed.

Based on today's visit, no deficiencies observed.

Exit interview conducted and a copy of the report will be emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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