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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920122
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:55:19 PM

Document Has Been Signed on 07/25/2024 01:55 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:ANGELS SUNRISE VILLA INC.FACILITY NUMBER:
315920122
ADMINISTRATOR/
DIRECTOR:		KUMAR, ALPESHFACILITY TYPE:
740
ADDRESS:2060 DONOVAN DRIVETELEPHONE:
(916) 847-0842
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 0DATE:
07/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Alpesh KumarTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 25, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. This facility has a fire clearance for 5 nonambulatory and one bedridden. Facility has all required postings in the main entryway.

LPA toured the facility with Administrator Alepsh. The following areas were inspected for compliance: kitchen, backyard, resident rooms, resident bathrooms, common areas, and garage. Facility has a current fire extinguisher and a full first aid kit. Medications will be kept locked in the laundry room. Cleaning chemicals and knives/sharps will be kept locked and inaccessible to residents.

Component III has been waived.

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: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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