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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317807
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:44:36 PM

Document Has Been Signed on 09/07/2022 03:44 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: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: 6DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sharon DillardTIME 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 09/07/2022 at 2:30 PM. LPA Martinez met with Sharon DIllard and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The facility has submitted a Covid-19 mitigation plan and a Infection Control plan. The facility has one main screening entry point, and an area for visits. The facility has a 30 day supply of PPE, and conducts daily disinfecting cleaning. The facility was sanitary, and the furniture is spaced 6 feet apart. The facility fire alarms, fire extinguisher were in good repair. The facility had an adequate supply of food. The facility chemicals were locked, and laundry room was sanitary. The facility has a first aid kit, and medications are locked and made inaccessible. The exterior emergency gate was in good repair. LPA Martinez also reviewed 3 employee files and 3 resident files, and all the files were up to date.

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

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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