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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005162
Report Date: 05/17/2021
Date Signed: 05/17/2021 12:54:18 PM

Document Has Been Signed on 05/17/2021 12:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LOVE AND DIVINE HOME CAREFACILITY NUMBER:
347005162
ADMINISTRATOR:SARCADI, DENISFACILITY TYPE:
740
ADDRESS:6525 GREENHAVEN DRIVETELEPHONE:
(916) 591-0801
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
05/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Denis SarcadiTIME COMPLETED:
01:00 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
Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? ​​No
· Fever or chills ​ · Cough ​· Shortness of breath/difficulty breathing · Fatigue ​· Muscle or body aches ​· Headaches ​· New loss of taste or smell ​
· Sore throat ​· Congestion or runny nose ​· Nausea or vomiting ​· Diarrhea​
Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? ​No
Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE?​ No
Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? ​No
Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No
Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No
Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 5/17/21 at 10:30am. LPA met with Denis Sarcadi Administrator and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents.

The temperature inside the facility was measured at 72.2*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LOVE AND DIVINE HOME CARE
FACILITY NUMBER: 347005162
VISIT DATE: 05/17/2021
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
26
27
28
29
30
31
32
The hot water was measured at 116.6*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients.

The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees due in the amount of $494.50 -Pin number given as an option to pay online during this visit.
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager-updated certificate
Emergency Disaster Plan LIC610D and LIC610ES


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3