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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701485
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:26:32 PM

Document Has Been Signed on 10/09/2024 01:26 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:LOVING LEGACY SENIOR CAREFACILITY NUMBER:
342701485
ADMINISTRATOR/
DIRECTOR:		BANUVE, VENIANAFACILITY TYPE:
740
ADDRESS:8216 COTTON BALL WAYTELEPHONE:
(279) 229-7719
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 0DATE:
10/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Veniana Banuve. TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/9/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Loving Legacy Senior Care for the purpose of conducting a pre-licensing inspection. LPA met with applicant, Veniana Banuve and together conducted a tour of the home. Applicant is applying for an RCFE with a capacity for six (6) non-ambulatory residents.

LPA and applicant evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, 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 109 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications area secure from residents.

LPA and applicant conducted Component III orientation.

At the time of inspection, the applicant has met all requirements to obtain a license. LPA has no objections to the facility being licensed. LPA will contact CAB and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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