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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920122
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:44:28 PM

Document Has Been Signed on 10/23/2024 12:44 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: 4DATE:
10/23/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Alpesh KumarTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived unannounced to conduct a post-licensing inspection. LPAs met with administrator, Alpesh Kumar, who arrived at 11:30am.

LPAs and Administrator conducted a tour of the interior of the facility and inspected the physical plant, kitchen, bedrooms, bathrooms, laundry area, and backyard area. LPA observed the facility to be clean and in good repair. There is a pool on the property that is locked and inaccessible to the residents. There is sufficient furniture and lighting throughout the facility. LPA observed required 7 day non-perishable and 2 day perishable food. LPA observed locked medications, knives and toxins to be inaccessible to residents. LPA observed four (4) resident files and three (3) staff files to be organized and complete.

LPA requested the liability insurance.

LPA observed all required documents to be posted in entry.

Exit interview conducted. No deficiencies cited at this time.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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