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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920181
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:00:30 AM

Document Has Been Signed on 09/17/2024 11:00 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:KRISSUN PLACE LLCFACILITY NUMBER:
345920181
ADMINISTRATOR/
DIRECTOR:		KPULUN, THOMASFACILITY TYPE:
740
ADDRESS:5801 NORTH AVETELEPHONE:
(916) 813-0596
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 0DATE:
09/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Thomas KpulunTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analysts (LPAs) Cassie Yang and Graham Gunby arrived announced at the facility to conduct a pre-licensing inspection utilizing the inspection tool. LPAs met with Applicant Thomas Kpulun and explained the purpose of the visit.

During today's visit, LPAs and Applicant conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: three residents room, a staff room, bathroom, kitchen, backyard, outdoor shed and the common areas. LPAs observed a designated place to store and lock sharps, medications and toxins. LPAs observed the resident bedrooms to have the required furnitures. LPAs observed the facility to have seven days of nonperishable items. LPAs tested the fire alarms and carbon monoxide to ensure they are in working condition. No deficiencies observed during today's visit.

LPAs conducted Comp III with Applicant. LPAs provided Applicant a copy of LIC 311F, LIC 9182, LIC 624 and LIC 624A.

LPAs informed Applicant facility is not licensed until Applicant is informed by Centralized Application Bureau Analyst with a copy of facility license.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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