347000922-3-15-2024-27-AS-KVIA-D3DSZN-20240315141924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000922
Report Date: 03/15/2024
Date Signed: 03/15/2024 02:19:32 PM

Document Has Been Signed on 03/15/2024 02:19 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	CINDY CENDANA CARE HOME		FACILITY NUMBER:	347000922
ADMINISTRATOR:	CINDY CENDANA GULESSERIAN		FACILITY TYPE:	740
ADDRESS:	10108 MONTE VALLO COURT		TELEPHONE:	(916) 854-2574
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	6	CENSUS: 6	DATE:	03/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cindy Gulesserian		TIME COMPLETED:	02:30 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 03/15/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Cindy Gulesserian and a brief interview followed. DFA Certificate # 6024922740 Expires 2/20/25 LPA started the inspection in the kitchen. All sharps were locked and inaccessible to residents in care. LPA observed that all items in the cabinets and refrigerator were clearly dated and labeled. A sample menu was posted on the refrigerator. The DFA also led the LPA to additional food supplies stored in the garage. LPA also observed that there was a sufficient food supply for 2-days non-perishable and 7-days perishable. The 2 fire extinguishers were last inspected by Fire Code Safety Equipment on 12/28/23. LPA inspected the 3 double occupancy bedrooms. All contained the required furniture and furnishings to be in compliance at this time. LPA inspected 2 resident bathrooms. Both contained soap, paper towels and grab bars and were in compliance. LPA also measured the hot water to ensure it was between 105 and 120 degrees Fahrenheit to ensure compliance. LPA inspected linen cabinet and there were sufficient linens for the residents in care. LPA inspected medications and the medication log. Medications were stored in a locked cabinet off the dining area and were inaccessible to residents in care. Proper administration, storage and destruction procedures were reviewed. During this inspection, LPA observed residents participating in morning exercises. LPA reviewed logs that

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CINDY CENDANA CARE HOME	FACILITY NUMBER: 347000922
	VISIT DATE: 03/15/2024

NARRATIVE

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recorded other group activities that residents have participated in the past. LPA proceeded to inspect the exterior of the facility. There were no outbuildings of bodies of water present. There was a covered sitting area with a table and chairs along with a paved walking path for residents to enjoy. The grounds were free of debris.

LPA reviewed the files of 4 staff and 3 residents. All were in compliance at this time.

The following documents were obtained today:
LIC 500
Resident Roster
Lease Agreement
Facility Sketch
Liability Insurance

According to California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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