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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 03/03/2025
Date Signed: 03/03/2025 10:55:06 AM

Document Has Been Signed on 03/03/2025 10:55 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:		ALEKSANDR SHELUDCHENKOFACILITY TYPE:
740
ADDRESS:4901 MELVIN DRTELEPHONE:
(808) 228-0588
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
03/03/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Aleksandr SheludchenkoTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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On 03/03/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 01/29/2025 during annual inspection. LPA met with Administrator, Aleksandr Sheludchenko, and explained the purpose of the visit.

LPA explained to Administrator that failure to correct plan of correction by the given due date could and will result to $100 per day civil penalty until corrected.

On 01/29/2025, LPA cited the facility on CCR 87412(a)(11) and Licensee agreed upon a POC Due Date of 02/28/2025 to submit in LIC503 for all staff. Licensee did not ensure that the POC was corrected upon Due Date of 02/28/2025. LPA will be assessing a Civil Penalty of $100/day from 03/01/2025 to 03/03/2025 for this violation and will continue to accrue until POC is corrected.

On 01/29/2025, LPA cited the facility on HSC 1569.185(b)(1)(F) and Licensee agreed upon a POC Due Date of 02/28/2025 for Licensee is to pay annual fee and late fee by POC due date and send proof to LPA. Licensee did not ensure that the POC was corrected upon Due Date of 02/28/2025. LPA will be assessing a Civil Penalty of $100/day from 03/01/2025 to 03/03/2025 for this violation and will continue to accrue until POC is corrected.

On 01/29/2025, LPA cited the facility on HSC 1569.625(b)(1) and Licensee agreed upon a POC Due Date of 02/28/2025 for Licensee is to conduct initial training for all staff by POC due date and send proof to LPA. Licensee did not ensure that the POC was corrected upon Due Date of 02/28/2025. LPA will be assessing a Civil Penalty of $100/day from 03/01/2025 to 03/03/2025 for this violation and will continue to accrue until POC is corrected.

Please continue to LIC809C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 345002979
VISIT DATE: 03/03/2025
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On 01/29/2025, LPA cited the facility on CCR 87506(b)(15) and Licensee agreed upon a POC Due Date of 02/28/2025 for Licensee is to complete an admission agreement and appraisal for R1 and R2 by POC due date and send proof to LPA. Licensee did not ensure that the POC was corrected upon Due Date of 02/28/2025. LPA will be assessing a Civil Penalty of $100/day from 03/01/2025 to 03/03/2025 for this violation and will continue to accrue until POC is corrected.

On 01/29/2025, LPA cited the facility on HSC 1569.625(c) and Licensee agreed upon a POC Due Date of 02/28/2025 for Licensee is to complete a emergency drill by POC due date by POC due date and send proof to LPA. Licensee did not ensure that the POC was corrected upon Due Date of 02/28/2025. LPA will be assessing a Civil Penalty of $100/day from 03/01/2025 to 03/03/2025 for this violation and will continue to accrue until POC is corrected.

Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date.
Exit Interview was conducted. A copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
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