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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920158
Report Date: 08/27/2024
Date Signed: 08/27/2024 11:01:29 AM

Document Has Been Signed on 08/27/2024 11:01 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:3SCARE, LLCFACILITY NUMBER:
345920158
ADMINISTRATOR/
DIRECTOR:		SAYEH, VIVIENFACILITY TYPE:
735
ADDRESS:8616 TRAVARY WAYTELEPHONE:
(916) 585-1884
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
08/27/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicant- Vivien SayehTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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On 8/27/2024, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived announced at the facility to conduct a pre-licensing inspection. LPAs met with Applicant, Vivien Sayeh, and explained the purpose of the visit.

During today's inspection, LPAs and Applicant conducted a tour of the interior and exterior of the facility to ensure there is no immediate health, safety and personal rights violation. LPAs conducted a tour of four (4) private bedrooms, one (1) bathroom, laundry room, kitchen, garage, backyard, and common areas. LPAs observed resident bedrooms to have the proper furniture of comfortable bed, night stand, dresser, lamp and chair. LPAs observed the facility to have a proper storage for medications, toxins and sharps which is locked and inaccessible. LPAs observed facility to have ample supply of personal hygiene, linen, and non-perishable foods. LPAs observed the exterior of the facility to be free of obstruction. LPAs observed the facility to have the required posters of Community Care Licensing Division. LPAs observed fire extinguisher serviced on 4/8/24. The water temperature was at 116.1 degrees Fahrenheit in the bathroom sink, which is within the required range of 105 to 120. The temperature in the facility was 73 degrees Fahrenheit during the time of visit

LPAs provided Applicant a copy of LIC311C, LIC627C and LIC605A.

LPAs and Applicant completed the inspection tool and Comp III. Pre-Licensing completed and no deficiencies was observed. LPAs 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.

Exit interview conducted a copy of the report was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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