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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701349
Report Date: 05/28/2024
Date Signed: 05/29/2024 03:32:37 PM

Document Has Been Signed on 05/29/2024 03:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARDINAL CARE HOME, LLCFACILITY NUMBER:
392701349
ADMINISTRATOR/
DIRECTOR:		SHAFIQ, MOHAMMADFACILITY TYPE:
735
ADDRESS:1427 CARDINAL STREETTELEPHONE:
(209) 329-5362
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 4CENSUS: 0DATE:
05/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:SHAFIQ, MOHAMMADTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 05/29/2024, Licensing Program Analyst (LPA) Kesha Lewis and Licening program manager Liza King arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants, SHAFIQ, MOHAMMAD and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit.
This facility will be licensed to hold 4 residents, of which 4 may ambulatory in bedrooms .This facility is also awaiting vendorization from Valley Mountain Regional Center and will accept and hold Level 4I residents.

A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair. A tour of the kitchen area was toured. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in the kitchen. A first aid kit was observed and had all the required components. Fire extinguisher was purchased on 01/24/2024. A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted hazards were observed during this visit, there are hanging wires were observed and sharp tools were in the grass area. Perimeter gate was observed to be in good repair but not self latching. A tour of garage was conducted a washer and dryer was identified.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed rooms were missing chairs and resident room 3 was missing a dresser.

A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time. A tour of two resident restrooms were toured one bathroom needs to have the bathtub color corrected.

Pre-license is not passed at this time. License will reach out to LPA Lewis when corrections are made to reschedule the pre-licensing visit.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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