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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920076
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:50:25 PM

Document Has Been Signed on 09/29/2023 04:50 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:JONATHAN VILLAFACILITY NUMBER:
345920076
ADMINISTRATOR:DUMUK, IVY ROSEFACILITY TYPE:
735
ADDRESS:7728 BLACK SAND WAYTELEPHONE:
(650) 703-1217
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 3DATE:
09/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Romano Dumuk TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived for a pre-licensing inspection. LPA met with administrator, Romano Dumuk. Currently there are 3 residents residing within the facility. Fire clearance was granted on 09/29/23 for 4 ambulatory/ non ambulatory residents . Administrator certificate expires on 08/18/25 # 6056045735 .This application is a change in ownership (CHOW) .This address is currently licensed as EVE MANOR, Facility # 342700017.

LPA conducted facility tour with administrator. Facility was inspected both indoors and outdoors. Outdoors was clean, tidy with adequate shading. Outdoor exits are clear and accessible. Indoors has the requisite rooms for activities and dining. There is a locked closet for personnel and client records. The emergency exiting plan and emergency phone numbers are posted. Resident rights are posted, facility visiting policy is posted, licensing complaint poster is posted. Facility has a First Aid kit and centrally stored locked cabinet for medications. Facility temperature is maintained between 68 degrees and 85 degrees. The facility has adequate lighting throughout. All bedrooms have appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Water faucets are marked hot and cold with the hot water temperature at 112 degrees. Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Toxins and chemicals are appropriately locked in a cabinet. No hazardous debris noted. Kitchen is clean sanitary, and in good repair. The kitchen has operable appliances. All sharps are located in a locked drawer, and sufficient utensils are available. The 7 day non-perishable and 2 day perishable food requirement is met.

Component III was waived as the current administrator has been administrator for other ARF licensed by CCLD. LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.
Laura Munoz
Talwinder Bains
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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