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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920011
Report Date: 04/05/2023
Date Signed: 04/07/2023 10:32:23 AM

Document Has Been Signed on 04/07/2023 10:32 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:JVC LLCFACILITY NUMBER:
345920011
ADMINISTRATOR:CHANG, CHE CHIANGFACILITY TYPE:
740
ADDRESS:7845 DOMINION WAYTELEPHONE:
(530) 949-5259
CITY:ELVERTASTATE: CAZIP CODE:
95626
CAPACITY: 6CENSUS: 5DATE:
04/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Che Chiang ChangTIME COMPLETED:
04:00 PM
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On 4/5/2023 LPA Tryon visited the facility to conduct a prelicensing visit. LPA met with applicant Che Chiang Chang. The facility is currently licensed by the previous owner, and there are 5 residents in care.
LPA reviewed the CARE Tool for prelicensing with the applicant.
LPA toured the facility with applicant and current licensee. LPA viewed common areas, kitchen, dining room, bedrooms, bathrooms, laundry room, storage, garage, patio/yard.
Smoke detectors present and functioning. Carbon monoxide detectors installed. Fire extinguisher present and charged/checked recently.
The facility is in good condition and clean. All floors, ceilings/walls, doors, etc in good condition. The house is nicely furnished. Appropriate furniture present.
Food supplies are adequate to meet the requirement of 2 days perishable/7 days non-perishable.
Appropriate first aid supplies available, as well as emergency lighting.
Facility has appropriate forms for staff and resident files.

LPA reviewed the RCFE Orientation Component III with applicant. At this time, the applicant has completed the RCFE Orientation Component III.

At this time, the facility appears to be in substantial compliance with the regulations.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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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