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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340313329
Report Date: 06/25/2021
Date Signed: 06/25/2021 09:54:08 AM

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:CAROLYN MITCHELL'S LOVING CARE HOMEFACILITY NUMBER:
340313329
ADMINISTRATOR:MITCHELL, KASSIAFACILITY TYPE:
740
ADDRESS:7556 COSGROVE WAYTELEPHONE:
(916) 428-5738
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 0DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kassia Mitchell and Patrick Cain, AdministratorsTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 06/25/2021 at 8:45 AM to conduct an annual inspection visit. LPA met with administrators Kassia Mitchell and Patrick Cain and explained the purpose of the visit. Currently there are no resident’s living at the care home. Kassia will let Licensing know if in the future there are resident’s residing at the care home.

Administrator Kassia Mitchell holds current certificate # 6020161740 and expires on 9/5/2022. LPA toured the facility with administrators, Kassia and Patrick on 06/25/2021 at 9:00 AM.

LPA inspected Physical Plant, Common Areas, four Bedrooms, two Bathrooms, and Kitchen. Common area was clean and in good repair. All bedrooms had required furniture, bedding and lighting. Kitchen was clean and in good repair. The bathrooms were in sanitary condition, properly maintained and the hot water temperature was observed to be 119.5 degrees Fahrenheit. LPA observed knives and toxins to be locked away and inaccessible to clients. Medication cabinet is locked. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. The facility mitigation plan was submitted to CCLD, and it was approved on 4/5/2021. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan. LPA also conducted the infection control domain tool.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview was held and a report was given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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