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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002885
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:27:12 AM


Document Has Been Signed on 03/22/2023 11:27 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ACTING WITH LOVE ASSISTED LIVINGFACILITY NUMBER:
455002885
ADMINISTRATOR:TOMPKINS, TASHAFACILITY TYPE:
740
ADDRESS:2635 SAPPHIRE LANETELEPHONE:
(530) 941-1473
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:8CENSUS: 10DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tasha TompkinsTIME COMPLETED:
11:36 AM
NARRATIVE
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing them. LPA met with Licensee Tasha Tompkins.

This facility is currently undergoing an increase in capacity. Licensee added on a shared room. She requested an increase in capacity a few months ago and it has not been processed by Community Care Licensing Division (CCLD) yet. Licensee showed proof to LPA that she went to the Anderson Fire Department on her own for the increase and it was granted. Licensee requested an increase to 12 residents.

Licensee accepted two over the current license of eight due to the state of emergency due to weather and the two residents were affected due to flooding in the area. Discussed was notification to the CCLD regarding accepting the residents was discussed.

Today LPA did the following:
-obtained a copy of the LIC 200, Application, to increase the capacity and also request for all beds to be non-ambulatory
-contact information of the fire department
-a copy of the receipts the licensee paid when she went to the fire department on her own for the increase in capacity

-The following was requested:
-updated facility sketch that shall have include the addition that was added to the building and the number of residents per room
-LIC 309 Administrative Organization
-proof the Corporation is in good standing with the Secretary of State.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ACTING WITH LOVE ASSISTED LIVING
FACILITY NUMBER: 455002885
VISIT DATE: 03/22/2023
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LPA is going to request a new fire clearance for the facility upon receipt of the updated facility sketch and will ensure it is fully processed.

Multiple topics were discussed during today's visit.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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