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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001897
Report Date: 03/03/2025
Date Signed: 03/03/2025 02:47:59 PM

Document Has Been Signed on 03/03/2025 02:47 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:SIERRA SUMMIT HEAD INJURY CAREFACILITY NUMBER:
317001897
ADMINISTRATOR/
DIRECTOR:		PENNY MEARSFACILITY TYPE:
735
ADDRESS:5562 MONTCLAIR DRIVETELEPHONE:
(916) 632-9622
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 3DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:Addie ThomasTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Graham Gunby arrived on Monday March 3, 2025 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Gunby reviewed resident (3) and staff (3) files. All client files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Gunby and Administrator Assistant, Addie Thomas, toured the facility together to ensure the health and safety of residents in care. The areas toured included bedrooms (4), bathrooms, kitchen, laundry room, back yard and common areas. All chemicals and toxins were kept locked and inaccessible to clients. Facility has two fire extinguishers (kitchen, hallway). In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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