<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700009
Report Date: 05/28/2024
Date Signed: 05/28/2024 02:59:54 PM

Document Has Been Signed on 05/28/2024 02:59 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:ARCELY J PUA HOMECAREFACILITY NUMBER:
342700009
ADMINISTRATOR/
DIRECTOR:		PUA, ARCELY JFACILITY TYPE:
740
ADDRESS:914 DENSMORE WAYTELEPHONE:
(916) 300-5286
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Arcely PuaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday May 28, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (4) and staff files (2). All resident files contained the required paperwork. Staff files contained the required paperwork and training.

LPA Parks and Administrator Arcely toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

First aid kit is fully stocked. All required posting were observed. Fire extinguisher had a current inspection tag.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1