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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701397
Report Date: 06/10/2024
Date Signed: 06/11/2024 07:33:56 AM

Document Has Been Signed on 06/11/2024 07:33 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:CARING HEART IIFACILITY NUMBER:
342701397
ADMINISTRATOR/
DIRECTOR:		ADUCAYEN, KRISTINEFACILITY TYPE:
740
ADDRESS:7818 WYMARK DRIVETELEPHONE:
(916) 682-4742
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
06/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Kristine AducayenTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/10/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to conduct a Pre-Licensing Visit. LPA Pascua was greeted by applicant, Kristine Aducayen and explained the purpose of the visit. The purpose of this visit was to conduct a Change of Ownership Pre-Licensing Visit.

Current census was 6. A brief interview with Applicant Aducayen was conducted.
This facility current holds 6 residents, of which 1 may be bedridden located in Bedroom #1. 5 out 6 residents may be non-ambulatory. This facility also holds a dementia plan and has a hospice waiver for 6.
A tour of the facility was conducted. Smoke detectors and carbon monoxide was observed to be in good repair.
LPA toured the office area which holds, resident, staff and medication.
LPA reviewed 2 staff files and 2 resident files. Along with the applicant, the LPA reviewed, discussed and compared medication to medication dispensing logs. First aid kit was present and in compliance. The facility administrator holds a current certificate #6020119740 and expires on 09/08/2024.
LPA toured the living room. dining room, and all other areas intended for resident use. Furniture and furnishings were in good repair.
LPA toured the kitchen. LPA observed knives and sharps locked and made inaccessible. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply. Fire extinguisher was observed to be last serviced on 03/09/2024 by River City Fire Equipment Company.
LPA toured the outside area. Perimeter fence and gates were observed to be in good repair with no hazards present. Exit gate was observed and was in good repair.
LPA toured 2 resident bathrooms. Hot water temperature was taken to ensure compliance within 105-120 degrees. LPA observed grab bars present in both bathrooms.
LPA toured 6 resident bedrooms. Furniture and furnishings were observed to be sufficient to meet resident needs and were in good repair.
Washer and dryer were identified in the hallway. Laundry detergent, cleaning supplies and other toxins were locked and made inaccessible. LPA also identified additional linens in a cabinets adjacent to the washer and dryer.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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: CARING HEART II
FACILITY NUMBER: 342701397
VISIT DATE: 06/10/2024
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This facility has been observed to be in compliance at this time.

There were no deficiencies observed during the course of this Pre-licensing visit.

Applicant has already conducted Comp I and Comp II.
Comp III was reviewed with applicant.

Exit Interview was conducted and a copy of this report was provided to the applicant at the end of the visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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