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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700517
Report Date: 08/16/2023
Date Signed: 08/29/2023 09:56:24 AM


Document Has Been Signed on 08/29/2023 09:56 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:KIND CARE HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAHLON, HARDEEPFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY:6CENSUS: 4DATE:
08/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kashmindar KaurTIME COMPLETED:
02:30 PM
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Unannounced Plan of Correction visit was conducted on 08/16/2023 by Licensing Program Analyst (LPA) Charlie Yang to review and clear the deficiencies that were previously cited on 08/29/2022. This LPA was met by the facility designated Administrator, Kashmindar Kaur, and a brief interview was conducted with her at this time. Current census was 4 residents.
The following items were reviewed to make sure that they had been corrected and brought into compliance at this time:
  1. Based on observation, the licensee did not comply with the section cited above in that the hot water temperatures measured in the facility restrooms were at 121.2 degrees which posed an immediate health, safety or personal rights risk to persons in care.
  2. Based on observation, the licensee did not comply with the section cited above since it was discovered that cleaning supplies were accessible to residents and care under the kitchen sink and resident restroom which posed an immediate health, safety or personal rights risk to persons in care.
  3. Based on observation, the licensee did not comply with the section cited above in that the facility kitchen refrigerator was observed to be locked with a metal cord that would not allow access to the residents which posed an immediate health, safety or personal rights risk to persons in care.
  4. Based on observation, the licensee did not comply with the section cited above in that one of the resident bedrooms had been converted into a retreat style room for employees and board members visiting out of town or serving as an office space which poses/posed a potential health, safety or personal rights risk to persons in care.
  5. Based on observation, the licensee did not comply with the section cited above since facility exits were equipped with high locking mechanisms and cord locks on the facility driveway fence which posed an immediate health, safety or personal rights risk to persons in care.
There were no deficiencies observed or cited at this time. All of the above deficiencies, with Plan of Correction, were reviewed and cleared at this time.
Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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