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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701359
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:26:35 AM

Document Has Been Signed on 10/16/2025 11:26 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 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: 2DATE:
10/16/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jatinder Dhillon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/16/2025, Licensing Program Analyst (LPA) Campbell arrived unannounced to conduct a post-licensing visit. LPA Campbell met with Jatinder Dhillon, Administrator and explained the purpose of the visit. The community resides in a 1 story, 3 bedroom, 2 bathroom home. It is licensed to serve 4 developmentally disabled adults, age 18 to 59, 2 of whom may be non-ambulatory. Currently there are 2 ambulatory residents in care.

Upon entry, LPA Campbell observed no See Something, Say Something posters or contact information for the Ombudsman. LPA Campbell discussed the need for the posters with the administrator and provided information on how to obtain the posters for use in the facility for residents, providers and guests. In the kitchen, LPA Campbell observed enough perishable foods for 2 days and enough non-perishable foods for 7 days. Knives were locked in a cabinet and cleaning products were locked under the kitchen sink and inaccessible to residents. Weekly menus for meals were attached to the pantry door.

When LPA Campbell attempted to open a kitchen cabinet, it was observed to be broken and hanging by one hinge.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHELTERING ARMS LLC #3
FACILITY NUMBER: 502701359
VISIT DATE: 10/16/2025
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 LPA Campbell directed the administrator to remove the cabinet because it was a danger to residents. The administrator removed the cabinet during this visit. Per the administrator, he will replace the cabinet hinges within a month since the hinges must be ordered.

During a tour of the backyard, LPA Campbell observed a shaded seating area on green turf and a pomegranate tree. There is a cleared pathway to the street for emergencies. LPA Campbell then observed the medication closet which contained residents prescriptions. A first aid kit was present and contained scissors, tweezers, thermometer and a first aid manual.
The medication closet where medication is stored was locked and inaccessible to residents.

A smoke and carbon monoxide test was conducted and both were found to be functioning. The facility has one fire extinguisher purchased on 02/26/25 that is fully charged. The thermostat stated the indoor temperature was 69 degrees Fahrenheit (F) which is within the requirement of 68 degrees F and 85 degrees F. Furnishings for use by the residents met the needs of the residents. All residents have their own rooms and the rooms contained a bed with sheets, lamp, night stand, chair, closet and drawers.

LPA Campbell reviewed 2 residents files for the 2 people residing in the community and 2 files for the 8 caregivers on staff. All files were complete and all staff were found to have been fingerprint cleared as required. No deficiencies were observed and cited during this visit. Exit interview held and a copy of report left.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
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