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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095920009
Report Date: 01/02/2024
Date Signed: 01/02/2024 01:34:54 PM

Document Has Been Signed on 01/02/2024 01:34 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:CAMBRIDGE HOUSE LLCFACILITY NUMBER:
095920009
ADMINISTRATOR:PEREZ, ESTEFANIAFACILITY TYPE:
735
ADDRESS:3480 CAMBRIDGE RDTELEPHONE:
(916) 990-6215
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY: 4CENSUS: 0DATE:
01/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator- Estefania PerezTIME COMPLETED:
01:45 PM
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On 01/02/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak met with Licensee Estefania Perez to conduct an announced Pre-Licensing visit.

The facility has a fire clearance for four (4) ambulatory residents. The Licensee has a current administrator certification (#6062755735) with an expiration date of 08/07/24.

LPA and Licensee conducted a tour of the interior and exterior of the facility to ensure compliance with Title 22 regulations. Areas toured include but are not limited to, four (4) private residents bedrooms, two (2) bathrooms, common areas, kitchen, dinning room, laundry area, staff quarters and the backyard.

All bedrooms had furnishings which include, a bed for each resident, night-stand, lamp, and storage space.

LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. Water temperature was observed over 125 degrees Fahrenheit. Warning signs are posted

It was advised Licensee should store the knives in the kitchen in a locked cabinet so it will be easily accessible to a caregiver when they are cooking. Licensee is going to send LPA Ratajczak a picture of personal rights and Administrator certification once posted.

Licensee agrees to notify LPA once first consumer is admitted. LPA Ratajczak provided Licensee with LIC311C, records to be maintained at the facility.

Comp III completed. No deficiencies observed. LPA Ratajczak will notify Centralized Application Bureau (CAB) of inspection completion.



Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024
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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