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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920066
Report Date: 10/16/2023
Date Signed: 10/16/2023 10:09:56 AM


Document Has Been Signed on 10/16/2023 10:09 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:VAN MOORE VILLAFACILITY NUMBER:
345920066
ADMINISTRATOR:NICULAI, SEFORAFACILITY TYPE:
740
ADDRESS:8924 VAN MOORE LANETELEPHONE:
(916) 218-8355
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
10/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator,Sefora Niculai TIME COMPLETED:
10:20 AM
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On 10/16/23, Licensing Program Analyst (LPA) Talwinder Bains met with applicant Sefora Niculai to conduct a announced Pre- Licensing visit.

The facility has a fire clearance (09/12/23) for 6 bedridden residents in bedroom 1-6. Facility has no residents at this time. Applicant holds a current administrator certificate (# 6020302740 with expiration date 09/29/2024) .



LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA inspected 6 bedrooms for residents, 4 bathrooms, common area, family room, kitchen, laundry room ,garage and outdoor area. LPA observed facility to be properly furnished, including appropriate bedding and lighting in the facility . Bathrooms were in sanitary condition and properly maintained. This house is 2 story building and applicant clarified that only 1st floor will be used for residents and 2nd story is only for staff/owner residence use. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medications to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. Water temperature was observed at 110 degrees F. Applicant agrees to notify LPA once first resident is admitted. A working telephone has been set up for residents use.

Pre-licensing passed and Component III (RCFE) was waived. Facility has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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