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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701384
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:45:33 PM

Document Has Been Signed on 06/21/2024 04:45 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:HEARTED CARE ASSISTED LIVING FACILITYFACILITY NUMBER:
342701384
ADMINISTRATOR/
DIRECTOR:
GRIMESEY, RICHARDFACILITY TYPE:
740
ADDRESS:6053 36TH AVENUETELEPHONE:
(916) 519-0139
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY: 5CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Daniel AbetewTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 6/21/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Applicant, Daniel Abetew who assisted LPA in today’s inspection.

Administrator holds current certification #6067711740 and expires on 9/25/25. It was learned that this facility will be licensed to serve up to five (5) ambulatory residents only. There are no residents in care currently. LPA toured the facility with Daniel Abetew.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility is clean and furnished. LPA observed rooms to have required furniture. Although there were no residents, LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 70*F which is within the required range of 68-85*F. Hot water temperature was measured at 105.1*F and is within the required range of 105-120*F. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kit were up to date. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed no obstruction of emergency exits inside or outside of facility.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. Component III conducted with the applicant. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

Per the California Code of Regulations Title 22, no deficiencies were observed or cited.
An exit interview was conducted, and a copy of this report was given to the applicant.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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