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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002925
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:37:01 AM

Document Has Been Signed on 03/22/2023 11:37 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:LOVING-KINDNESS CAREHOME LLCFACILITY NUMBER:
315002925
ADMINISTRATOR:NINOBLA, DERBBIEFACILITY TYPE:
740
ADDRESS:912 OAK RIDGE DRTELEPHONE:
(916) 297-7694
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 3DATE:
03/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Derbbie NinoblaTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Lavinia Muscan and Auditor Jacqueline Juarez arrived at the facility unannounced on 3/22/23 to conduct a case management visit to request documents for a facility audit. LPA and Auditor met with Administrator, Derbbie Ninobla and explained the purpose of the visit.

Copy of admission agreement, physicians report and rent checks were reviewed and obtained. Needs and service plan to be emailed to CCLD.

As a result of today’s visit, no deficiencies were noted or cited.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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