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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920075
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:33:57 PM

Document Has Been Signed on 12/26/2024 04:33 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:PURE CARE HOMEFACILITY NUMBER:
345920075
ADMINISTRATOR/
DIRECTOR:		MESLOUB, SID ALIFACILITY TYPE:
740
ADDRESS:6355 PERRIN WAYTELEPHONE:
(916) 254-1412
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
12/26/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:35 PM
MET WITH:Sid MesloubTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On December 26, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the effective exclusion of an individual effective date December 26, 2024. LPA met with caregiver who then contacted Administrator who arrived to the facility shortly afterwards.

LPA and Administrator discussed S1 worked at the facility for approximately a month. Administrator confirmed S1 is no longer working at the facility. S1 is now separate from facility roster on Guardian.

No deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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