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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920132
Report Date: 07/11/2024
Date Signed: 07/11/2024 10:03:35 AM

Document Has Been Signed on 07/11/2024 10:03 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:KINGS PEAK HOME CAREFACILITY NUMBER:
315920132
ADMINISTRATOR/
DIRECTOR:
MALITSKIY, JULIEFACILITY TYPE:
740
ADDRESS:556 KINGS PEAK COURTTELEPHONE:
(916) 749-4020
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
07/11/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Julie Malitskiy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with Licensee/Administrator Julie Malitskiy during today's inspection.

Facility was inspected both indoors and outdoors. LPA inspected 6 resident bedrooms, 2 bathrooms, 1 staff room, common living areas, kitchen, garage, and outdoor areas. 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 stored in locked cabinet in the kitchen area. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Grab bars and non-skid mat was present in all bathrooms. Smoke detectors and carbon monoxide detectors were checked. Fire clearance was granted on 01/24/24 for 6 non-ambulatory residents. Kitchen is clean, sanitary, and in good repair. A working telephone has be set up for residents use.

Licensee agrees to notify LPA once first consumer is admitted. This report will be forwarded to the centralized application unit for continued processing. Comp III was waived.

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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