<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347000702
Report Date:
09/18/2024
Date Signed:
09/18/2024 02:32:22 PM
Document Has Been Signed on
09/18/2024 02:32 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
INDOCARE HOUSE 1
FACILITY NUMBER:
347000702
ADMINISTRATOR:
LOMENDEHE, PAUL
FACILITY TYPE:
740
ADDRESS:
8278 NEWFIELD CIRCLE
TELEPHONE:
(916) 682-5461
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95828
CAPACITY:
6
CENSUS:
5
DATE:
09/18/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Jendri Kolibu
TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/18/24 at 2:15pm Licensing Program Analyst (LPA) made an unannounced Plan of Correction (POC) inspection to ensure pervious deficiencies have been addressed and corrected.
LPA observed the door to the back bedroom has been replaced/repaired and is in compliance with Title 22 regulations.
LPA also addressed an advisory note issued during previous inspection regarding the non-ambulatory status of a resident who's 602 identifies the resident as bed bound in comments and selected both non-ambulatory and bedridden on the resident's 602 (physician's report).
LPA again asked again and provided clarification for the need of an updated LIC 602 to ensure the resident is appropriately placed and the facility is in compliance with their fire clearance.
POC letter generated and a copy of this report and POC letter was left at the facility.
SUPERVISOR'S NAME:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1