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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701359
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:50:02 PM

Document Has Been Signed on 04/04/2024 02:50 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:SHELTERING ARMS LLC #3FACILITY NUMBER:
502701359
ADMINISTRATOR/
DIRECTOR:		DHILLON, JATINDERFACILITY TYPE:
735
ADDRESS:2929 AGRESTI DRIVETELEPHONE:
(209) 535-7588
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 4CENSUS: 4DATE:
04/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jatinder Dhillon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 04/04/2024, Licensing Program Analyst (LPA) Renee Campbell arrived announced to conduct a Pre-Licensing Visit. LPA Campbell met with applicant Facility Designated Administrator, Jatinder Dhillon and explained the purpose of the visit. The purpose of this Pre-Licensing Visit is due to opening a new facility and to ensure compliance with Title 22 regulations.

The licensee will be the administrator of this facility. The facility administrator’s certificate # 6047876735 will expire on 04/23/2024. Facility has a fire clearance for 2 ambulatory clients and 2 non-ambulatory client. Bedroom 3 is reserved for 2 non-ambulatory residents with 2 beds. Bedrooms 1 and 2 are reserved for ambulatory residents. There is also a meeting room that will be used as an office. This Applicant is seeking licensure for a 3 bedroom Adult Residential Facility (ARF) to accept and retain adult clients at any given time. The facility will not employ staff who are live-in caregivers but will have staff working shifts throughout the day/night for proper 24-hour care and supervision. There were no residents in care at this time. LPA Campbell toured the facility and reviewed the facility sketch and the facility reflected the approved fire clearance STD 850 document.

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 located in the dining area and is in good condition. A tour of the common room was conducted, and furniture and furnishings were observed to be well kept. A tour of the backyard was conducted and no hazards were present. Perimeter gate was observed to be in good repair. The emergency exit was not obstructed. LPA Campbell observed adequate roof covering for patio. A tour of garage was conducted. A washer and dryer were identified.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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: SHELTERING ARMS LLC #3
FACILITY NUMBER: 502701359
VISIT DATE: 04/04/2024
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Detergent, toxins, and other cleaning supplies were observed to be locked and made inaccessible under the sink. A tour of the client bedrooms was conducted. Furniture and furnishing were observed to meet the client needs. A linen closet was in the hallway and was observed to have a sufficient amount of linen to meet the client needs at this time.
A test was conducted for smoke and carbon monoxide alarms and were observed to be functional. The hot water in the bathroom was measured at 111 degrees Fahrenheit.
Component III was completed successfully.
Requirements for pre-licensing inspection met.
Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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