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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701150
Report Date: 07/19/2022
Date Signed: 07/25/2022 09:00:36 AM

Document Has Been Signed on 07/25/2022 09:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:KAREN CARES HOMEFACILITY NUMBER:
052701150
ADMINISTRATOR:PUENTE, KARENFACILITY TYPE:
735
ADDRESS:2378 VISTA DEL LAGOTELEPHONE:
(209) 584-9047
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 4DATE:
07/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Karen Puente, AdministratorTIME COMPLETED:
01:20 PM
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On 07/19/2022 at 12:00 pm, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a Pre-licensing inspection. LPA met with Administrator, Karen Puente and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 4 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. LPA observed no bodies of water. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.4 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Carbon monoxide was in operating condition during inspection. Based on observation and interview, smoke detector is interconnected with the fire department. Fire extinguisher was last serviced on July 19, 2022. First aid kit was observed to be complete. Fire drill was last conducted on 06/18/2022.

LPA conducted Component III presentation.

Exit interview conducted with Administrator and copy of this report was provided to applicant for signature. Report sent to the applications unit as this facility is ready for licensure.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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