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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005155
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:28:40 PM


Document Has Been Signed on 06/08/2023 12:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ALOHA ASSISTED LIVINGFACILITY NUMBER:
347005155
ADMINISTRATOR:GRACE F. DULAYFACILITY TYPE:
740
ADDRESS:7816 TIGERWOODS DRIVETELEPHONE:
(916) 502-5057
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 4DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Grace DulayTIME COMPLETED:
12:40 PM
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 arrived unannounced to conduct an annual inspection on 6/8/23. LPA met with Licensee Grace Dulay and explained the purpose of the visit. The Administrator certificate expires 3/21/24 for Grace Dulay. There are 4 residents in care currently.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA observed rooms to have required furniture. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which shall be maintained on the premises. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 118.6*F which is within the required range of 105-120*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed.

LPA requested resident and staff files for review. LPA reviewed (4) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALOHA ASSISTED LIVING
FACILITY NUMBER: 347005155
VISIT DATE: 06/08/2023
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
26
27
28
29
30
31
32
The following forms and documents were requested to be submitted within 15 days:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, and Administrator Certificate.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2