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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004441
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:35:05 AM


Document Has Been Signed on 10/17/2022 11:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMFORT LIVING ELDER CAREFACILITY NUMBER:
347004441
ADMINISTRATOR:JESUSA NAGTALONFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariam SoumahoroTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/17/2022. LPA met with Mariam Soumahoro and explained the purpose of the visit.

The purpose of the visit today, is in response to an administrator change for this facility. LPA Martinez became aware that an administrator change was done on 10/17/2022. LPA Martinez requested the following documents:

LIC 200 Application


LIC 500 Personnel Report (Staff Schedule)
LIC 501 Personnel Record (Administrator Application/Education)
LIC 308 Responsibility of Designation

Once documents are received, Community Care Licensing Department (CCLD) will review the documents. CCLD will review the documents for approval. Please email documents to LPA Martinez by 10/21/2022 by close of business 5PM.

Exit interview conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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