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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317807
Report Date: 11/03/2023
Date Signed: 12/04/2023 05:16:05 PM


Document Has Been Signed on 12/04/2023 05:16 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ALLEN'S CARE HOMEFACILITY NUMBER:
340317807
ADMINISTRATOR:ALLEN, MELVINAFACILITY TYPE:
735
ADDRESS:3701 KNIGHTLINGER STREETTELEPHONE:
(916) 922-9211
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 1DATE:
11/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Melvina AllenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA)s Jamie Ivey Canady at the facility unannounced to conduct a case management quarterly visit based on previous Non-Compliance meeting dated 08/04/2023. LPA Ivey Canady explained the purpose of the visit and was met by Melvina Allen.

LPA Ivey Canady conducted a tour of the facility and found the fire extinguisher to be dated May 2023. Facility administrator is listed as Kanisha Golden, administrator certificate # 6017595735 expiring on 08/01/2024. Administrator Certificate application for Melvina Allen has been submitted and due to Department backlog has not been received. LPA requested and received current P&I staff training documentation with staff sign in sheet dated 8/2023. LPA requested and received documentation pertaining to facility renovated garage while facility still in the process of getting fire clearance.

LPA observed the facility kitchen and living areas to be clean and free of debris. LPA observed the facility resident rooms to be clean, beds made and all furniture in each room based on Title 22 regulations.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to Administrator Melvina Allen.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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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