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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700767
Report Date: 04/09/2020
Date Signed: 04/21/2021 10:01:11 AM

Document Has Been Signed on 04/21/2021 10:01 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ALLTRUE CARE LLCFACILITY NUMBER:
342700767
ADMINISTRATOR:KACHAN, VICTORIAFACILITY TYPE:
740
ADDRESS:9977 WYLAND DRIVETELEPHONE:
(530) 215-8388
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
04/09/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Victoria KachanTIME COMPLETED:
04:00 PM
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Announced Component III visit made out to this facility via Facetime on 04/09/2020 by LPA Charlie Yang and LPA Anthony Tuck who were met by the Applicant Victoria Kachan. Brief interview was conducted with the Applicant.
It was learned that this facility will be seeking licensure to serve up to (6) residents at any given time. This Applicant is also accepting residents diagnosed with dementia and a hospice waiver to accept and retain up to (6) hospice residents at any given time.
There were no resident in care during today's Component III interview.
A review of the Component III was conducted with the Applicant.

Exit Interview
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2020
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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