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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340309927
Report Date: 03/04/2025
Date Signed: 03/04/2025 03:45:22 PM

Document Has Been Signed on 03/04/2025 03:45 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PRISCILLA CARBONELL'S CARE HOMEFACILITY NUMBER:
340309927
ADMINISTRATOR/
DIRECTOR:		CARBONELL, PRISCILLAFACILITY TYPE:
740
ADDRESS:NO. 1 TIMBERWOOD COURTTELEPHONE:
(916) 929-4566
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Aaron Johnson JarrellTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Holly Williams arrived unannounced to conduct an annual inspection. LPA Williams talked with facility administrator on the phone Priscilla Carbonell and explained the purpose of the visit. Priscilla Carbonell stated that Aaron Johnson Jarrell can sign for her.

LPA Williams reviewed three resident files (R1-R3) and two staff files (S1-S2).

LPA Williams toured the facility with Jovelyn Jarrell and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 114.8 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed a locked cabinet for the storage of medication. LPA Williams observed unlocked cabinet in the hallway with cleaning solutions and a unlocked garage with cleaning solutions, laundry solutions, knives and other tools.

LPA Williams interviewed 1 staff member (S1-S2) and 1 resident (R1).

This facility is being cited per 22 CCR Section 87309(a) An exit interview was held with Aaron Johnson Jarrell. Appeal rights and a copy of the report was left with Aaron Johnson Jarrell.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161
DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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Document Has Been Signed on 03/04/2025 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: PRISCILLA CARBONELL'S CARE HOME
FACILITY NUMBER: 340309927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above and had cleaning solutions, laundry detergents, and knives that are accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee agrees to put a lock on the garage door that needs a key or code to get in to the garage. Conduct training for all staff on locking up cleaning solutions and laundry detergent within 2 weeks of the POC due date. Licensee to send a statement stating the Title 22 regulation that was cited by the POC due date. Holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025

LIC809 (FAS) - (06/04)
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