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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002972
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:59:20 AM

Document Has Been Signed on 02/06/2025 11:59 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOOD SAMARITAN CARE FACILITYFACILITY NUMBER:
345002972
ADMINISTRATOR/
DIRECTOR:		DANIELYAN, DANIELFACILITY TYPE:
740
ADDRESS:4406 BARRETT ROADTELEPHONE:
(916) 458-2615
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Daniel DanielyanTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On 02/06/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPA met with Administrator Daniel Danielyan and explained the purpose of the visit.

LPA and Administrator conducted a tour of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, and common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven(7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 02/12/2024. Administrator stated they have an appointment tomorrow 02/07/2025 to have fire extinguishers inspected. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of two (2) resident files and two (2) staff files. LPA provided Administrator with a copy of LIC311F, records to be maintained at the facility.

LPA requested Licensee email LPA Ratajczak current LIC500 and LIC308.

As a result of today's inspection no deficiencies observed.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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