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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002918
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:27:31 PM

Document Has Been Signed on 11/20/2023 01:27 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADONAI CARES FOR ELDERLYFACILITY NUMBER:
345002918
ADMINISTRATOR:SAMUELS, OLAWUMIFACILITY TYPE:
740
ADDRESS:5532 HONOR PARKWAYTELEPHONE:
(310) 272-3318
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 3DATE:
11/20/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator, Olawumi SamuelsTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 11/20/23 to conduct the Post Licensing inspection. LPA met with administrator, Olawumi Samuels who assisted LPA during today's inspection.

No deficiencies were observed or cited during today's visit.
See LIC809 for Annual Inspection report for 11/20/23 for details.

Exit interview conducted. A copy of this report was printed and given to Administrator.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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