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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001897
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:58:56 AM

Document Has Been Signed on 02/14/2024 10:58 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:SIERRA SUMMIT HEAD INJURY CAREFACILITY NUMBER:
317001897
ADMINISTRATOR:PENNY MEARSFACILITY TYPE:
735
ADDRESS:5562 MONTCLAIR DRIVETELEPHONE:
(916) 632-9622
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Addie Thomas, House ManagerTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday February 14, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (4) and staff files (4). All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Parks and House Manager Addie toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

First aid kit was fully stocked. Facility has PPE and covid tests on site. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed.

LPA obtained updated copies: LIC500, LIC610D, and activity calendar.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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