<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004293
Report Date: 07/05/2024
Date Signed: 07/05/2024 10:25:34 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/05/2024 10:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:George Kakuta, Licensee TIME COMPLETED:
10:40 AM
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
Licensing Program Analyst (LPA) Tung Truong made an announced visit to conduct a required 1 year annual visit. LPA met with Licensee George Kakuta and stated the purpose of today’s visit. There are no residents residing in this facility currently.

Licensee reported that the facility has been temporary closed for two years due to COVID-19 pandemic. LPA toured the facility with Licensee George Kakuta. Licensee stated that he will move back into the facility around August or September. Licensee understood that the facility shall remain compliance with Title 22 Regulations. Licensee stated that he will notify Licensing when the facility starts having residents again. Administrator certificate expires on 08/26/2024.

Per California Code of Regulations, Title 22 Division no deficiencies were cited during this visit. Exit interview was held, and a copy of report this was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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