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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340309927
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:20:47 PM


Document Has Been Signed on 01/12/2023 03:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PRISCILLA CARBONELL'S CARE HOMEFACILITY NUMBER:
340309927
ADMINISTRATOR:CARBONELL, PRISCILLAFACILITY TYPE:
740
ADDRESS:NO. 1 TIMBERWOOD COURTTELEPHONE:
(916) 929-4566
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 3DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jessica JarrellTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 01/12/2023 at 2:20 PM. LPA met with Jessica Jarrell and stated the purpose of today’s visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate expires on 07/07/2024. The facility is licensed for four ambulatory residents and two non-ambulatory residents. There are currently 3 residents who reside at this facility.

LPA Martinez toured the facility with Jessica Jarrell on 01/12/2023 at 2:20 PM.

The facility has submitted a Covid-19 mitigation plan, and has Covid-19 postings throughout the facility. The facility has one main screening entry point, and has a 30 day supply off PPE. The facility furniture is space six feet apart, and conducts daily cleaning. The facility smoke and carbon detectors are in good repair. The fire extinguisher is in good repair. The last fire drill was on 01/01/2023. The first aid kit is in good repair. The facility files are up to date.

The facility kitchen is sanitary and has an adequate food supply. The facility also has emergency food kit. The facility bathrooms are sanitary and in good repair. The resident bedrooms are in good repair and sanitary. The exterior back yard is clear of derbies, and the exterior emergency exit gate is in good repair.

As a result of this visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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