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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920010
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:16:29 PM

Document Has Been Signed on 06/20/2023 02:16 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:ALOHA CARE HOMEFACILITY NUMBER:
315920010
ADMINISTRATOR:QUEBADA, KATHRYN M.FACILITY TYPE:
740
ADDRESS:6017 SHIMMER FALLS DRTELEPHONE:
(916) 467-8910
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
06/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kathryn Quebada, LicenseeTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with licensee Kathryn Quebada and Administrator Nicole Quebada during today's visit.

Facility was inspected both indoors and outdoors. LPA inspected 4 resident bedrooms, 3 bathrooms, common living areas, garage and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in the kitchen area cabinet. The facility has adequate lighting throughout and night lights in the hallways. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 05/05/23 for 6 non-ambulatory. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use.

Competent III was completed during today's inspection with licensee. Licensee is required to contact Community Care Licensing upon the admittance of their first consumer, after licensure. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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