<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701499
Report Date: 12/09/2024
Date Signed: 12/09/2024 12:39:12 PM

Document Has Been Signed on 12/09/2024 12:39 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:LUSH CARE-RIVERHAVENFACILITY NUMBER:
342701499
ADMINISTRATOR/
DIRECTOR:
BUKSH, SHABANAFACILITY TYPE:
740
ADDRESS:8563 MCCLOUD RIVER WAYTELEPHONE:
(650) 727-2457
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 0DATE:
12/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Shabana BukshTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/09/24, Licensing Program Analyst (LPA) Kimberly Viarella made an announced prelicensing inspection. LPA identified herself upon arrival, stated the purpose of the visit and met with the Licensee/Administrator, Shabana Buksh. A brief interview followed.

The facility has applied for a license for 6 ambulatory residents with a hospice waiver of 2. LPA conducted an inspection of the facility including but not limited to the 3 resident bedrooms, office, and two bathrooms, all of which contained the required furniture, furnishings, and lighting to be in compliance at the present time. The kitchen, living room, dining room, laundry room, and garage were also inspected.

LPA observed the locked closet where medications for future residents will be stored so that they remain inaccessible to residents in care. LPA also inspected the first aid kit and it contained all of the required items to be in compliance at the time of this inspection.

This facility had no bodies of water or outbuildings present on its grounds. LPA conducted an inspection of the perimeter and found the exterior to be in good repair and the grounds to be free of debris.

LPA Viarella noted no health and safety concerns at this time.

LPA Viarella conducted the Component III portion of the application process and will notify the CAB analyst that the Pre-Licensing is complete and this facility has no deficiencies.

Per California Code of Regulations (CCR) - Title 22, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1