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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002941
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:38:42 PM

Document Has Been Signed on 03/12/2025 03:38 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KOTA CAREFACILITY NUMBER:
315002941
ADMINISTRATOR/
DIRECTOR:		RAMONA MCGILLFACILITY TYPE:
740
ADDRESS:1652 MARKDALE LANETELEPHONE:
(530) 379-6708
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 3DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Administrator - Ramona McGillTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Graham Gunby arrived on Wednesday March 12, 2025 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Gunby reviewed resident (3) files. All resident files contained the required paperwork. LPA observed all of the required posted documents.

LPA Gunby and Administrator Ramona toured the facility together to ensure the health and safety of resident in care. The areas toured included bedrooms, bathrooms, kitchen, common areas, back yard and garage. All chemicals, toxins, and sharps were kept locked and inaccessible to residents. Facility has one (1) fire extinguisher, in the kitchen. In the areas toured, there were no health or safety violations observed.

LPA requested (2) staff files and the facility liability insurance be submitted by 03/13/2025.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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