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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700570
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:18:58 PM

Document Has Been Signed on 08/06/2024 04:18 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SEN'S CAREGIVINGFACILITY NUMBER:
342700570
ADMINISTRATOR/
DIRECTOR:		PRASAD, INDRA SENFACILITY TYPE:
740
ADDRESS:5250 SHORTWAY DRTELEPHONE:
(916) 471-9145
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 2DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Indra Prasad TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 8/6/2024, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year inspection visit. LPA met with Administrator Indra Prasad explained the purpose of the visit.

Administrator current certification expires on 11/13/2024. Current census is 2. LPA toured the facility with Indra Prasad and staff Ekshay Sen.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed two day perishables and seven day non-perishables. The hot water temperature was measured at 113.7*F which was within the required range of 105-120*F. The temperature inside the facility measured at 78*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.


Continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SEN'S CAREGIVING
FACILITY NUMBER: 342700570
VISIT DATE: 08/06/2024
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LPA requested resident and staff files for review. LPA reviewed (2) staff files and (2) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following forms and documents were requested to be submitted within 15 days:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview conducted, and a copy of report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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