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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701108
Report Date: 04/27/2023
Date Signed: 05/02/2023 04:35:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/02/2023 04:35 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MB ADULT RESIDENTIAL CARE HOMESFACILITY NUMBER:
392701108
ADMINISTRATOR:KAUR, KULJITFACILITY TYPE:
735
ADDRESS:15833 SOUTH AIRPORT WAYTELEPHONE:
(209) 679-9938
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 0DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:No One PresentTIME COMPLETED:
11:00 AM
NARRATIVE
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Unannounced annual visit made out to this facility on 04/27/2023 by Licensing Program Analyst (LPA) Charlie Yang.
Several attempts were made to ring the doorbell and gain access into this facility. After several minutes without any response, this LPA retreated back to his car.
A phone call was made to the facility contact number, (209) 679-9938, and this LPA was able to make contact with the facility designated Administrator, Kuljit Kaur, at this time.
A brief interview was conducted with the facility designated Administrator at this time.
She stated that after the Prelicensing visit that was conducted on 04/08/2022 by CCL and this LPA, this facility has not been vendorized through Valley Mountain Regional Center.
She stated that they have been waiting for vendorization and this facility, although it has been licensed, has been empty without any residents or staff.
She stated that no physical plant changes have been made or attempted since the last Prelicensing visit.
This LPA advised her to please inform CCL and this LPA once vendorization has been approved and placement of residents take place.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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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