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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002979
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:18:53 AM

Document Has Been Signed on 09/01/2023 11:18 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: 3DATE:
09/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen LimTIME COMPLETED:
11:30 AM
NARRATIVE
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An office meeting was conducted on September 1, 2023 with Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100. Present in the meeting was Administrator/Licensee, Karen Lim, Property owner, Antolin Gonzales, Licensing Program Manager (LPM), Laura Munoz, and Licensing Program Analyst (LPA), Cassie Yang to discuss the Department's expectations if Licensee was to close the facility and/or change of ownership.

LPM discussed California Code Regulation 87109 Transferability of License and Health Safety Code 1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties. Copy of the sections was also provided.

Additionally, LPM and LPA emphasized to Licensee, 60 day notices are to be sent LPA prior to distributing to residents and responsible parties. Licensee was informed she is to be responsible of the facility during the change of ownership until applicant is licensed. LPM informed Property owner and Licensee that Licensee will need to be issued a leaseback agreement during the change of ownership.


Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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