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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701231
Report Date: 01/05/2023
Date Signed: 01/17/2023 05:00:49 PM

Document Has Been Signed on 01/17/2023 05:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHELTERING ARMS LLCFACILITY NUMBER:
502701231
ADMINISTRATOR:DHILLON, JATINDERFACILITY TYPE:
735
ADDRESS:3401 PUMA WAYTELEPHONE:
(209) 535-7588
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 4CENSUS: 0DATE:
01/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jatinder and Davinder DhillonTIME COMPLETED:
12:00 PM
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Announced Prelicensing visit made out to this facility on 01/05/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jatinder Dhillon and his wife Davinder Dhillon. Brief interview was conducted with the facility designated Administrator and his wife at this time.
Current census was (0) residents.
It was learned that this facility was vendorized through Valley Mountain Regional Center and will be able to accept and retain up to (4) Level 4I residents at any given time.
Tour of the facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient supply of plates, silverware, and items necessary to meet the needs of the residents at this time.
A review of the facility food supply was conducted to make sure that there was an adequate 2-day perishable and 7-day nonperishable amounts at all times. Pantry area was toured.
Cleaning supplies and agents were observed to be present under the kitchen sink cabinet and were locked and made inaccessible to the residents at this time.
Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Fire extinguisher(1), located hanging in the dining area was observed to have been purchased on 11/07/2022 and in compliance at this time.
A tour of the facility resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms(2) was conducted. Grab bars were observed to be in place and able to serve the needs of the residents at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cabinets housing detergents, bleach, and all other laundry supplies were observed to be locked to make these items inaccessible to the residents at all times.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SHELTERING ARMS LLC
FACILITY NUMBER: 502701231
VISIT DATE: 01/05/2023
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A tour of the facility garage area was conducted. Cabinets housing additional items for resident use were reviewed. Additional freezer unit was observed to be present to store additional food items for use by this facility.
Linen closet was observed to contain the necessary supplies and items in order to meet the needs of the residents at this time.
Medication closet, located in entry way, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications were reviewed with the facility designated Administrator at this time. A review of the facility medication administration record (MAR) was conducted.
First aid kit was present and observed to contain all of the required components at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL at this time:

LIC 308

LIC 400

LIC 500

LIC 610

This facility has been found to be in compliance at the time of this Prelicensing visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
LIC809 (FAS) - (06/04)
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