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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002972
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:30:18 PM

Document Has Been Signed on 05/04/2023 01:30 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:GOOD SAMARITAN CARE FACILITYFACILITY NUMBER:
345002972
ADMINISTRATOR:DANIELYAN, DANIELFACILITY TYPE:
740
ADDRESS:4406 BARRETT ROADTELEPHONE:
(916) 458-2615
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:45 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
Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit. LPA met with Olha Vaynahiy, who contacted Administrator immediately.

During today's visit, LPA and Vaynahiy toured the lower level of the facility and confirmed no residents at the facility as this time. At this time, facility does not have an active liability insurance.

No deficiencies cited. LPA was unable to print out a new license as no comments have not been updated. New license will be provided once updated, approximately on 5/5/2023.

Exit interview conducted, a copy was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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