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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005570
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:55:39 PM

Document Has Been Signed on 01/08/2025 01:55 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:CLARA CARE HOMEFACILITY NUMBER:
347005570
ADMINISTRATOR/
DIRECTOR:		KIM, JAE YOELFACILITY TYPE:
740
ADDRESS:4665 FREEWAY CIRCLETELEPHONE:
(916) 900-4781
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 5DATE:
01/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Okki and Jae KimTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 1/8/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with caregiver. LPA and caregiver notified administrators Jae and Okki Kim, who arrived to assist.
LPA is continuing review of R1's death on 12/1/24.

LPA reviewed R1's file and received additional documents. LPA reviewed S2's file and observed S2 had required training.
LPA interviewed S2, R2 and R3.

Review of R1's medication records found some centrally stored medication and destruction records missing, Administrator will request duplicate records for the pharmacy and will complete R1's medication destruction records.

No finding was made at this time. R1's coroner report is pending.

As a result of today’s inspection, no deficiencies were noted.

Report reviewed. Copy of report.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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