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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920171
Report Date: 10/02/2024
Date Signed: 10/02/2024 10:14:07 AM

Document Has Been Signed on 10/02/2024 10:14 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:CARE RANCH, THEFACILITY NUMBER:
315920171
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ-RUBIN, SHERYLFACILITY TYPE:
735
ADDRESS:1716 MCCOURTNEYTELEPHONE:
(415) 609-7301
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 4CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sheryl Hernandez-RubinTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived on Tuesday October 2, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. LPA reviewed one (1) resident file and one (1) staff file. All files contained the required paperwork. Facility has all required postings in the entry way.

LPA toured the facility with Administrator Sheryl. The following areas were inspected for compliance: garage, kitchen, resident rooms, bathrooms, backyard, and common areas. Facility has current fire extinguisher, carbon monoxide detector, and fully stocked first aid kit. Medications, files, and knives are kept locked in a closet in the laundry room. Cleaning chemicals are kept locked in the hallway closet 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 emailed to the facility.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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