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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002500
Report Date: 01/03/2024
Date Signed: 02/20/2024 02:40:56 PM

Document Has Been Signed on 02/20/2024 02:40 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:CABALLO HOUSEFACILITY NUMBER:
045002500
ADMINISTRATOR:WILSON, BRANDENAFACILITY TYPE:
735
ADDRESS:4229 CABALLO WAYTELEPHONE:
(530) 342-2329
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 6CENSUS: 2DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator- Carrie Segee TIME COMPLETED:
12:15 PM
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On 01/03/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Carrie Segee and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 120 F. LPA observed two (2) fire extinguishers, six (6) fire detectors, and two (2) carbon monoxide detectors. LPA observed a complete first aid kit. LPA observed locked medication and cleaning supplies inaccessible to the residents.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of two (2) residents' files and three (3) staff files. All of which had the required documentation.

Several topics were discussed.

No deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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