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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 08/28/2023
Date Signed: 08/28/2023 06:42:32 PM


Document Has Been Signed on 08/28/2023 06:42 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: 4DATE:
08/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Mae CastenadaTIME COMPLETED:
06:55 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management health and safety check for the residents in care. LPA met with Caregivers, Mae Castaneda and Tim Baquerfo, Landlord, Antolin Gonzales, Licensee associates Travis and Owy Holmquist to discuss the current issue at the facility.

LPA observed the presence of four residents in care. LPA spoke with caregivers and residents to ensure residents' needs are met.

LPA contacted interim Administrator, who informed LPA she was not an Administrator at the facility. LPA was informed that interim Administrator was present at the facility on August 14th and August 28th.

Today's observation will be under review. No deficiencies cited today.

Exit interview conducted a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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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