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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004293
Report Date: 06/30/2021
Date Signed: 07/07/2021 09:08:59 AM

COMPREHENSIVE INSPECTION
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:MIDORI-EN CARE HOMEFACILITY NUMBER:
347004293
ADMINISTRATOR:MIDORI KAKUTAFACILITY TYPE:
740
ADDRESS:3119 MILL OAK WAYTELEPHONE:
(916) 922-3098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:4CENSUS: 0DATE:
06/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Kakuta Midori TIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 07/07/2021 at 9:00 AM. LPA Martinez met with Kakuta Midori and stated the purpose of today’s visit.

Kakuta Midori reported the facility is temporally closed, and there are no resident and no staff. LPA Martinez observed the facility to be empty. LPA Martinez toured the facility with Kakuta.



Kakuta Midori is the administrator of this facility, and holds a current administrator certificate. The administrator certificate expires on 08/26/2022-6017399740.

Per California Code of Regulations, Title 22 Division no deficiencies were observed and cited during this visit. Exit interview held, Copy of report given
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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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