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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701442
Report Date: 07/02/2024
Date Signed: 09/18/2024 07:11:55 AM

Document Has Been Signed on 09/18/2024 07:11 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:EZ CAREFACILITY NUMBER:
342701442
ADMINISTRATOR/
DIRECTOR:		KAKUTA, MODORIFACILITY TYPE:
740
ADDRESS:6240 FENNWOOD CT.TELEPHONE:
(916) 716-9596
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 2DATE:
07/02/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Midori Kakuta (Administrator), Khaula Nixon (Licensee)TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census: 2
Method: Telephone call with CAB
COMP II Participants: Midori Kakuta (Administrator), Khaula Nixon (Licensee) & Tammy Edwards, (Analyst).

Licensee & administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the Licensee and administrator was verified by confirming driver’s license number. During COMP II, licensee and administrator confirmed the understanding of Title 22. Component II was successfully completed. Licensee and administrator were advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Licensee & Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
It was also discussed that due to Ambulatory only fire clearance, that the licensees/administrators are not authorized to care for residents with dementia.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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