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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920067
Report Date: 12/18/2023
Date Signed: 12/18/2023 10:04:53 AM

Document Has Been Signed on 12/18/2023 10:04 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:LOVE YOU DADFACILITY NUMBER:
315920067
ADMINISTRATOR:GERGI, EDUARDFACILITY TYPE:
740
ADDRESS:5024 SOUTHSIDE RANCH RDTELEPHONE:
(916) 807-4319
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 7CENSUS: 6DATE:
12/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Eduard GergiTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday December 18, 2023 to conduct an unannounced prelicensing visit. This is a change of ownership with residents in care.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. LPA reviewed 6 resident files and 4 staff files. All files contained the required paperwork. This facility has a fire clearance for 4 nonambulatory and two bedridden resident, with a total capacity of 6. Facility has all required postings in the hallway.

LPA toured the facility with Administrator Eduard. The following areas were inspected for compliance: kitchen, backyard, resident apartments, resident bathrooms, and common areas. Facility has current fire extinguishers and a full first aid kit. Medications are kept locked in a cabinet in the dining area. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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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