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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005864
Report Date: 02/03/2025
Date Signed: 02/03/2025 10:09:38 AM

Document Has Been Signed on 02/03/2025 10:09 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:QUEEN OF HEARTS ELDERCAREFACILITY NUMBER:
347005864
ADMINISTRATOR/
DIRECTOR:		CINDY,SOTOFACILITY TYPE:
740
ADDRESS:9464 OAK AVETELEPHONE:
(916) 988-6764
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 14CENSUS: 12DATE:
02/03/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Caregiver Maria SandovalTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 2/3/25 to conduct a health and safety check. LPA met with Caregiver Maria Sandoval and explained the purpose of the visit.

During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted. LPA requested LIC500 and Resident roster to be emailed to LPA by end of week.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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