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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920092
Report Date: 01/10/2024
Date Signed: 01/10/2024 10:42:49 AM

Document Has Been Signed on 01/10/2024 10:42 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:SAKURA HOME CAREFACILITY NUMBER:
315920092
ADMINISTRATOR:MALITSKIY, JULIEFACILITY TYPE:
740
ADDRESS:1220 HORTON LNTELEPHONE:
(279) 900-8464
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
01/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julie Malitskiy, AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a pre-licensing inspection. LPA met with Licensee/Administrator Julie Malitskiy during today's visit. Currently there are 6 clients residing within the facility.

Facility was inspected both indoors and outdoors. LPA inspected 6 client bedrooms, 3 bathrooms, 1 staff room, 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 hallway closet. The facility has adequate lighting throughout. Water temperature was observed at 120 degrees F. LPA inspected client bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Smoke detectors and carbon monoxide detectors were operational. Fire clearance was granted on 10/30/2023 for 6 non-ambulatory clients. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for client use.

This report will be forwarded to the centralized application unit for continued processing. COMP III was completed during today's inspection.

Exit interview and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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