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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005155
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:33:04 AM


Document Has Been Signed on 05/01/2024 10:33 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:ALOHA ASSISTED LIVINGFACILITY NUMBER:
347005155
ADMINISTRATOR:GRACE F. DULAYFACILITY TYPE:
740
ADDRESS:7816 TIGERWOODS DRIVETELEPHONE:
(916) 647-9331
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:4CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Grace DulayTIME COMPLETED:
11:00 AM
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On 5/1/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year visit. LPA met with Administrator Grace Dulay and explained the purpose of the visit.

Administrator holds current certification #6012122740 and expires on 3/21/24. Renewal application is currently pending. The facility is licensed to serve four residents ages 60 and above. Two may be non-ambulatory. Hospice approved for two (2) residents. There are 4 residents in care currently.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 119.3*F which was within the required range of 105-120*F. The temperature inside the facility was observed at 72*F which was within the required range of 68-85*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.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALOHA ASSISTED LIVING
FACILITY NUMBER: 347005155
VISIT DATE: 05/01/2024
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LPA requested resident and staff files for review. LPA reviewed two (2) staff files and four (4) resident 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.

The following forms and documents were requested:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. Exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2