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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340302276
Report Date: 06/20/2024
Date Signed: 06/20/2024 10:18:42 AM


Document Has Been Signed on 06/20/2024 10:18 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:FLOWERDALEFACILITY NUMBER:
340302276
ADMINISTRATOR:HUFFHINES, JERRY L.FACILITY TYPE:
735
ADDRESS:7446 8TH STREETTELEPHONE:
(916) 991-3791
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:11CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jerry Huffhines, LicenseeTIME COMPLETED:
10:45 AM
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****This is a 1 year Annual Review Inspection- The inspection Tool did not populate for this review****

On June 20, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an Annual Inspection. LPA met with Jerry Huffhines, Licensee, and informed him the reason for the visit.

Jerry and LPA was not able to complete the Infectious Control Questionnaire due to the type of visit did not have the annual as an option.

LPA inspected the interior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required.
LPA reviewed 2 resident records and 1 staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to Jerry.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than July 20, 2024.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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