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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920112
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:13:19 AM


Document Has Been Signed on 03/19/2024 11:13 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:CARTER HOUSE SENIOR LIVINGFACILITY NUMBER:
315920112
ADMINISTRATOR:CARTER, TERESAFACILITY TYPE:
740
ADDRESS:251 GREY COURTTELEPHONE:
(773) 203-6964
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 5DATE:
03/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Teresa CarterTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday March 19, 2024 to conduct an unannounced prelicensing visit. This is a change of ownership with residents in care.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. LPA reviewed 5 resident files and 2 staff files. All files contained the required paperwork. This facility has a fire clearance for 6 nonambulatory residents, with a total capacity of 6. Facility has all required postings in the entry way.

LPA toured the facility with Administrator Teresa. The following areas were inspected for compliance: kitchen, backyard, resident rooms, bathrooms, and common areas. Facility has current fire extinguisher and a full first aid kit. Medications are kept locked in a cabinet in the kitchen area. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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