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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920121
Report Date: 04/03/2024
Date Signed: 04/03/2024 10:21:32 AM


Document Has Been Signed on 04/03/2024 10:21 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:HARJIT AND NAVGEET RCFE IIFACILITY NUMBER:
345920121
ADMINISTRATOR:KAUR, NAVGEETFACILITY TYPE:
740
ADDRESS:4400 BELMONT PLACE LANETELEPHONE:
(916) 514-8957
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Navjeet KaurTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/3/24 to conduct a Prelicensing Inspection utilizing the CARE tool. LPA Met with the licensee.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA, reviewed two resident and one staff file. Files contained necessary information.

Component III was waived.

No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance.

License is pending.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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