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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701170
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:40:14 PM

Document Has Been Signed on 07/25/2022 03:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:YOUNG AT HEART RCFE NO.4 INCFACILITY NUMBER:
342701170
ADMINISTRATOR:SISAYAN, LILLIANFACILITY TYPE:
740
ADDRESS:9012 COLOMBARD WAYTELEPHONE:
(916) 682-6080
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Glenda Molinyawe/ Lillian SisayanTIME COMPLETED:
03:50 PM
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On July 25, 2022 at 2:08pm Licensing Program Analyst (LPA) Chris Hopkins arrived at Young at Heart RCFE NO.4 Inc, for the purpose of conducting an unannounced Pre-Licensing inspection. LPA was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility. LPA met with Administrator Glenda Molinyawe and together conducted a tour of the home. Licensee Lillian Sisayan showed up at a later time.

LPA inspected the kitchen, resident bedrooms, resident bathroom, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 106 degrees F which meets the 105-120 degree Fahrenheit regulation. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. First aid kit was checked and is complete. LPA observed centrally stored medications locked. Cleaning supplies kept locked in laundry room and locked in storage closet. LPA observed a sufficient supply of towels and linens able to meet the needs of the residents. The facility has an approved LIC 808 mitigation plan on file and uploaded into FAS.

The facility currently has 6 residents residing at the home at this time.


LPA reviewed the Component III orientation with Licensee. Component III orientation successfully completed.

LPA recommends moving forward with licensure. Exit interview was conducted and a copy of report provided to facility representative.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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