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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701150
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:13:26 PM

Document Has Been Signed on 08/06/2024 01:13 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KAREN CARES HOMEFACILITY NUMBER:
052701150
ADMINISTRATOR/
DIRECTOR:
PUENTE, KARENFACILITY TYPE:
735
ADDRESS:2378 VISTA DEL LAGOTELEPHONE:
(209) 584-9047
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Karen Puente TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/06/2024 at 11:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Karen Puente and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for four ambulatory clients. There are currently four clients who reside at this facility.

The LPA Martinez toured the facility with Karen Puente on 08/01/2024 at 12:30 PM.

LPA Martinez reviewed 4 client files and 3 staff files, which were maintained and complete. LPA Martinez reviewed one medication administration record (MAR) and one PNI ledger, which records were maintained and complete. The facility has an infection control plan and has a natural disaster plan. The fire extinguisher, carbon detector, and smoke detectors are in good repair. The last fire drill was on July 30, 2024. The facility inflatable jacuzzi is enclosed by a secured locked gate. In addition, the Jacuzzi is covered. Facility staff has updated their facility sketch to reflect the location of the jacuzzi. Facility sketch will be emailed to LPA Martinez by August 08, 2024 5:00 PM. The facility common areas are sanitary and furnished, and the facility has an adequate food supply. Resident bedrooms and bathrooms are sanitary and furnished. The facility temperature measured at 75 degrees, and the facility water temperature measured at 108 degrees. The exterior of the facility is clear of debris and has an patio area for client use.

Based on this annual inspection there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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