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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000922
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:19:32 PM


Document Has Been Signed on 06/01/2023 12:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CINDY CENDANA CARE HOMEFACILITY NUMBER:
347000922
ADMINISTRATOR:CINDY CENDANA GULESSERIANFACILITY TYPE:
740
ADDRESS:10108 MONTE VALLO COURTTELEPHONE:
(916) 854-2574
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:6CENSUS: 6DATE:
06/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cindy CendanaTIME COMPLETED:
12:30 PM
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On 6/1/23 at 11:15am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management Inspection to deliver the department's findings regarding the reported injury and death of a resident. LPA met with Licensee Cindy Gulesserian and together discussed the department's investigation.

The department conducted interviews with facility staff members who witnessed the reported incident. Interview statements were consistent with the report received by the department. According to hospital records and interviews, there is no suspicion of abuse and no concerns were raised by hospital staff. resident's fall was determined to accidental with no foul play suspected. No parties interviewed expressed concerns regarding the facility or the care provided to residents. Residents who were able to be interviewed expressed positive feelings regrading their placement at the facility. All residents who could not be interviewed appeared well cared for.

The department has determined the concerns of questionable death to be unsubstantiated. There is not a preponderance of the evidence to prove that an alleged violation occurred. If any additional information is received this determination can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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