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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920158
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:52:29 PM

Document Has Been Signed on 01/14/2025 02:52 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:3SCARE, LLCFACILITY NUMBER:
345920158
ADMINISTRATOR/
DIRECTOR:		SAYEH, VIVIENFACILITY TYPE:
735
ADDRESS:8616 TRAVARY WAYTELEPHONE:
(916) 585-1884
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 1DATE:
01/14/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Administrator Viven SayehTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/14/2025 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassandra Mikkelson arrived at the facility unannounced to conduct a post licensing inspection. LPAs met with Administrator Viven Sayeh and explained the purpose of the visit. Today's census is one (1) resident. Facility is licensed for four (4) residents with one (1) being non- ambulatory

LPAs and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, dinning room, garage and common areas. LPAs observed sharps, toxins and medication to be locked and secured. LPAs observed the facility to have two (2) days of perishable and seven (7) days of nonperishable foods. LPAs observed fire extinguisher to be last serviced on 04/08/2024. LPAs and Administrator completed the post-licensing inspection tool and facility was found to be in compliance.

LPAs conducted a file review of one (1) resident file and one (1) personnel file.

LPA Ratajczak requested Administrator to send a copy of the LIC500 and LIC308 by 01/17/2025.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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