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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701452
Report Date: 09/26/2024
Date Signed: 09/27/2024 09:35:54 AM


Document Has Been Signed on 09/27/2024 09:35 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:KINDNESS RESIDENTIAL CAREFACILITY NUMBER:
502701452
ADMINISTRATOR:RADAZA, NICETAS FARAFACILITY TYPE:
740
ADDRESS:5707 CHANCELLOR WAYTELEPHONE:
(209) 869-4750
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 5DATE:
09/26/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicetas RadazaTIME COMPLETED:
01:00 PM
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Unannounced Post Licensing visit made out to this facility on 07/01/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Nicetas "Nancy" Radaza. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 5 residents.
It was learned that there was (1) resident under the care of hospice at this time.
This facility does have an approved hospice waiver to be able to accept and retain up to (6) hospice residents at any given time.
It was learned that there were (3) residents receiving care from a home health care agency at this time.
It was learned that there was (1) resident diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility Applicant/designated Administrator Nicetas Radaza. Additional forms and documents were reviewed to make sure that the initial certification process was completed and a valid certificate was issued in compliance at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in a separate dining area cabinet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated representative at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KINDNESS RESIDENTIAL CARE
FACILITY NUMBER: 502701452
VISIT DATE: 09/26/2024
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105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Assured Fire Extinguisher Company, on 01/15/2024 and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (4) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's Post Licensing visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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