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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004652
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:30:42 PM

Document Has Been Signed on 05/15/2024 02:30 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:CONCEPCION HOMEFACILITY NUMBER:
097004652
ADMINISTRATOR/
DIRECTOR:		CONCEPCION, FIDELINAFACILITY TYPE:
735
ADDRESS:409 CRANSTON COURTTELEPHONE:
(916) 941-1507
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 3CENSUS: 3DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator Fidelina ConcepcionTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on 5/15/2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Muscan reviewed client (3) and staff files (2). All client files contained the required paperwork. Staff have current first aid and CPR training.

LPA Muscan and Administrator toured the facility together to ensure the health and safety of clients in care. The areas toured included client rooms, bathrooms, kitchen, garage, and backyard. Water temperature is within the required range of temperatures. In the areas toured, there were no health or safety violations observed.

LPA requesting updated copy of LIC500, current liability insurance, and an updated copy of the LIC610E to be sent in to CCLD by the end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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