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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005563
Report Date: 12/30/2024
Date Signed: 12/30/2024 01:16:24 PM

Document Has Been Signed on 12/30/2024 01:16 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:HAMPSHIRE MANOR INCFACILITY NUMBER:
317005563
ADMINISTRATOR/
DIRECTOR:
CATHY DUSTINFACILITY TYPE:
740
ADDRESS:1203 HAMPSHIRE COURTTELEPHONE:
(916) 742-5386
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Cathy Dustin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/30/2024 LPA Tryon visited the facility unannounced to conduct an annual visit. LPA was greeted by staff, who contacted Administrator Cathy Dustin. Ms. Dustin arrived a short time later.
The facility currently has 6 residents. 1 resident is using hospice services.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, yard, storage, garage. The home is clean, well-furnished and in good repair. Food supplies were reviewed and are adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Food appears to be varied and of good quality. Cleaning supplies and other potentially dangerous items are secured. Medications are centrally stored, logged and locked. Rooms are nicely furnished with appropriate furniture. There are games, books and activities available. Bathrooms are in good condition and clean, plumbing fixtures clean and operable.
LPA reviewed 2 resident files and 2 staff files. Appropriate documentation is present.
LPA spoke briefly with resident and one staff.

LPA reviewed the CARE Tool with Ms. Dustin.

At this time, it appears the facility is in substantial compliance with regulations.
Exit interview conducted.
Troy OrdonezTELEPHONE: (916) 263-4832
Todd TryonTELEPHONE: (916) 263-4700
DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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