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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701168
Report Date: 07/09/2024
Date Signed: 07/09/2024 11:07:34 AM

Document Has Been Signed on 07/09/2024 11:07 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:YOUNG AT HEART RCFE NO.3 INCFACILITY NUMBER:
342701168
ADMINISTRATOR/
DIRECTOR:		SISAYAN, LILLIANFACILITY TYPE:
740
ADDRESS:9375 BROWNSBERG WAYTELEPHONE:
(916) 681-3689
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 6DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Glenda MolinyaweTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 7/9/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year visit. LPA met with facility staff Glenda Molinyawe explained the purpose of the visit.

Administrator current certification expires on 8/8/2025. This facility is licensed to serve six (6) non-ambulatory of which one (1) may be bedridden. Hospice approved for two. The current census is 6 with three facility staff. LPA toured the facility with Glenda Molinyawe

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 supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 109.8*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*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. Proof of current liability insurance was observed.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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: YOUNG AT HEART RCFE NO.3 INC
FACILITY NUMBER: 342701168
VISIT DATE: 07/09/2024
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LPA requested resident and staff files for review. LPA reviewed (3) staff files and (6) 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.

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 violations were observed. An exit interview was conducted, and a copy of this report was provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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