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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701150
Report Date: 11/16/2022
Date Signed: 11/17/2022 07:52:40 AM

Document Has Been Signed on 11/17/2022 07:52 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:
11/16/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Candice Summers - Direct Care StaffTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Post Licensing Inspection Visit. LPA met with direct care staff 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 with direct care staff 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 71 degrees 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 107.3 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7 day non-perishables 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 10/18/2022.

LPA reviewed four (4) staff records and two (2) resident records. All staff are fingerprint cleared and have current first aid certificates. All residents have required documents for community care licensing (CCL).

No deficiencies were cited from California Code of regulations, Title 22, Division 6, 8.

An exit interview was conducted with direct care staff and copy of report was left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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