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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:16:50 PM


Document Has Been Signed on 08/20/2024 03:16 PM - 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:
08/20/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Reality WattsTIME COMPLETED:
03:15 PM
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On 8/20/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit regarding the facility's plans of doing a change of ownership. LPA met with Caregiver and explained the purpose of the visit.

During today's visit, it was discussed that Licensee is to provide a 60 day change of ownership notice to resident, responsible parties and the Department a copy of the notice. Additionally, it was discussed that current Licensee is still responsible for the facility to ensure facility is in compliance until new applicant is approved and licensed.

LPA provided Administrator a copy of Guardian Roster, CCR 87355 Criminal Clearance Record.

At this time, LPA is requesting for the required documents to appoint new facility Administrator:
- copy of Administrator Certificate
- ID/DL
- LIC 9182 CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST

An office meeting will be held if needed to support Licensee and new Applicant regarding change of ownership.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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