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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 07/13/2023
Date Signed: 07/13/2023 12:15:29 PM


Document Has Been Signed on 07/13/2023 12:15 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:
07/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karen LimTIME COMPLETED:
11:00 AM
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On 07/13/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility and spoke with Administrator, Karen Lim. The purpose of this visitation was a Plan of Correction (POC) visit regarding the citations issued on 07/06/2023, as a result of the case management visit.

During today's visit, LPA cleared the following citations:

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

As a result of today's inspection, deficiencies was cited.

An exit interview was conducted and copy of report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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