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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095920083
Report Date: 03/26/2024
Date Signed: 03/26/2024 11:14:12 AM

Document Has Been Signed on 03/26/2024 11:14 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARLSON SPRINGS ARFFACILITY NUMBER:
095920083
ADMINISTRATOR:NGWANGBURUKA, IHEOMAFACILITY TYPE:
735
ADDRESS:4241 CARLSON WAYTELEPHONE:
(530) 888-5000
CITY:DIAMOND SPRINGSSTATE: CAZIP CODE:
95619
CAPACITY: 12CENSUS: 0DATE:
03/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Administrator, Iheoma NgwangburukaTIME COMPLETED:
11:30 AM
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On 03/26/24, Licensing Program Analyst (LPA) Talwinder Bains met with Administrator, Iheoma Ngwangburuka to conduct a announced Pre- Licensing visit. Facility staff were also present including Ifeanyi Ezeani (C.E.O.),Safaratu Okolo (ED), Rachel Breedlove (Regional Director), Michelle Frase (Chief of Staff) ,Sarena Christensen (Facility Manager) during this visit. The facility has a fire clearance (10/27/23) for 12 ambulatory residents. Facility has no residents at this time.


LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA inspected 6 bedrooms for residents, 3 bathrooms, common area, 1 staff room, kitchen, Play/games/office area , laundry area, Office and outdoor area. Facility has no garage. LPA observed facility to be properly furnished, including appropriate bedding and lighting in the facility . Bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. 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 at the care home to be operational. Fire extinguisher last serviced on 09/29/23 and first aid kit are maintained and ready for emergency use. All required postings were observed. Inside temperature was 65 degree F . Licensee agrees to notify LPA once first consumer is admitted. A working telephone has been set up for residents use.

Pre-licensing passed and Component III (ARF) was waived as administrator is associated with other facilities by department . Facility has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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