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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002811
Report Date: 01/24/2024
Date Signed: 01/24/2024 11:37:54 AM


Document Has Been Signed on 01/24/2024 11:37 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:BU-WON CARE HOMEFACILITY NUMBER:
347002811
ADMINISTRATOR:YANG, BU-WON K.FACILITY TYPE:
740
ADDRESS:1035 ELSWORTH WAYTELEPHONE:
(916) 467-7510
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 2DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Buwon YangTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/24/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with the Licensee/ Administrator and explained the purpose of the visit. .

LPA and Admin toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedroom, medication rooms, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed. The facility is clean and well maintained.
Residents observed appeared to be assisted as needed with an appropriate number of staff present.

LPA reviewed 2 resident files. Files were complete.

2 Staff files were reviewed. Files are complete.

LPA received a copy of the liability Ins. certificate.

LPA and Licensee discussed several issues.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted. Report provided copy provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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