576804337-9-18-2025-21-AS-JNAA-DLMVJR-20250918162909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 576804337
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:30:30 PM

Document Has Been Signed on 09/18/2025 04:30 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CASCADE SENIOR CARE HOME LLC		FACILITY NUMBER:	576804337
ADMINISTRATOR/ DIRECTOR:	DHILLON, SUKHJINDER K.		FACILITY TYPE:	740
ADDRESS:	2725 CASCADE ST.		TELEPHONE:	(916) 213-1942
CITY:	WEST SACRAMENTO	STATE: CA	ZIP CODE:	95691
CAPACITY: 6		CENSUS: 0	DATE:	09/18/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:06 PM
MET WITH:	Sukhjinder K. Dhillo, Administrator and Manjit Padda, House Manager/Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	On 09/18/2025 Licensing Program Analyst (LPA) Nakagawa conducted a pre-licensing inspection and was greeted by Licensee/Administrator applicant Sukhjinder K. Dhillon and Manjit Padda, House Manager/Caregiver. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 6 Nonambulatory. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. There is an apartment which can be accessed from the outside of the facility which is currently being rented, but may be converted to staff apartment; current resident has fingerprint clearance. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. Fire extinguisher stored in kitchen area was purchased on 03/22/2025: found to be fully charged. There are (2) carbon monoxide detectors: tested and operational. There are (8) smoke detectors, all of which were found to be in working order. Emergency exits are marked and unobstructed. Exterior doors are armed with auditory alarms. Water was measured 116.0 - 116.2 F in faucets used by clients which falls within regulation between 105 & 120 degrees F. There was an ample supply of linens with appropriate bedding equipped in Resident rooms. There is an additional supply of hygiene, continence and paper products. Hallways are equipped with several night lights for accessibility and resident bedrooms have appropriate furnishings. There is a sufficient amount of dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in designated drawer and under the kitchen sink. Cleaning products and other toxins and chemicals are kept out of resident access and found secured in the garage and laundry room cabinets. LPA observed adequate supply of both perishable and non-perishable food sufficient for (6) residents in care. The facility will be conducting weekly grocery replenishment with consideration to resident preferences and dietary restrictions. A sample menu is also located on the refrigerator and indicates a healthy and balanced set of meals for residents in care. Continued onto LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CASCADE SENIOR CARE HOME LLC	FACILITY NUMBER: 576804337
	VISIT DATE: 09/18/2025

NARRATIVE

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(Continued from LIC809...)

Medications are centrally stored and secured in locked cabinets located in kitchen with Centrally Stored Medication Records and several other medication related forms on file. Resident specified files including care plans, medical reports and dietary restrictions are located in a designated cabinet in the kitchen. There is also an office area located in the living room with all appropriate staffing records, program operation documentation and emergency disaster information. Licensing form templates pertaining to these sections have also been prepared. The facility will begin hiring direct support staff as needed.

The backyard features a well-landscaped yard with seating for resident and visitor outdoor use. Windows, screens and blinds are all found to be in good repair. Emergency evacuation maps and clear exit signs are observed posted at each exit door. A sign in sheet with proper screening devices and protection equipment were observed at the front entrance. The facility and facility operation plan are found to be adequate and tour of the facility completed.

Licensee will be sending a copy of the updated liability insurance to CCLD. Component III orientation was conducted with the Licensee/Administrator Applicant and House Manager. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with Licensee/applicant and a copy was provided to the Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC809 (FAS) - (06/04)

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