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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700517
Report Date: 08/29/2024
Date Signed: 08/30/2024 05:26:17 PM


Document Has Been Signed on 08/30/2024 05:26 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:KIND CARE HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAUR, KASHMINDERFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Kashmindar KaurTIME COMPLETED:
03:30 PM
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Licensing Program Analyst Jason Lund arrived unannounced to conduct an annual/required visit. Administrator, Kashmindar Kaur, came a short time later. This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory and non- ambulatory. Census: 4

LPA Lund and Administrator Kashmindar Kaur tour/inspected was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time.Drawers containing knives and other cutlery were observed to be locked and made inaccessible to the residents at this time.

Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Additional nonperishable food items were observed to be stored in the garage area along with an additional refrigerator unit. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. Resident’s bedrooms were inspected. Furniture and furnishings were observed to be present and maintained in compliance at this time. Resident’s restrooms were inspected. Shower areas, toilets, and wash basins were reviewed and observed to be functional and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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: KIND CARE HOME II
FACILITY NUMBER: 502700517
VISIT DATE: 08/29/2024
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Medication for resident use, located in kitchen cabinet, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time. Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 05/29/2024 from the local fire extinguisher company, and in compliance at this time. First aid kit was observed to be present and contained all of the required components at this time.

Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use. Laundry area, located adjacent to kitchen area, was observed to be made inaccessible to the residents at this time. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored in cabinets where they were locked and made inaccessible to the residents at this time.

Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.

Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility. A review of (4) facility personnel files was conducted. A review of (3) facility resident files was conducted.

No deficiencies were observed during this visit. Exit Interview and report given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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