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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585920143
Report Date: 05/02/2024
Date Signed: 05/02/2024 09:52:28 AM

Document Has Been Signed on 05/02/2024 09:52 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HUMBLE ABODE CARE HOMEFACILITY NUMBER:
585920143
ADMINISTRATOR/
DIRECTOR:		BAL, JAGDEEPFACILITY TYPE:
735
ADDRESS:5545 SUNHAVEN ST.TELEPHONE:
(530) 701-4037
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 0DATE:
05/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Benita Velenzuela LopezTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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LPA Hiratsuka conducted this announced prelicensing. LPA met with Facility Representative Benita Velenzuela Lopez. Applicant Jagdeep Bal, could not be present during the visit but appointed Benita Velenzuela Lopez to represent him. Facility Representative is the administrator for two of Applicant's other facilities.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. There are four private resident rooms. None of the rooms have exits to the outside. The largest room has a full private bathroom. There is one full common bathroom. There is a laundry room with an exit to the outside behind the kitchen. There are locked cabinets for medications and records. The backyard is very large. There is a fence that divides the backyard into two spaces. There is a door to the garage from inside the facilty.

LPA is waiving component III orientation due to Facility Applicant and Facility Representative owning and operating other facilities.

This facility meets all requirements. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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