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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004613
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:39:30 PM


Document Has Been Signed on 03/05/2024 12:39 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CROWN JEWEL VILLAFACILITY NUMBER:
347004613
ADMINISTRATOR:DASCALESCU, IONELFACILITY TYPE:
740
ADDRESS:5422 YDRA COURTTELEPHONE:
(916) 989-5511
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Luminita Dascalescu, LicenseeTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 3/5/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

There are no residents residing at the facility at this time. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathroom for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA checked medication storage and found medication to be inaccessible to residents.

LPA requested copies of Administrator certificate and liability insurance. Administrator will inform the Department upon admission of the first resident.

As of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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