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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317807
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:02:06 PM

Document Has Been Signed on 10/23/2023 12:02 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:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Willie AllenTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual inspection. LPA Ivey Canady met with Shakera Barnes and stated the purpose of today’s visit. Facility licensee Willie Allen arrived for today's visit approximately 1 hour into the visit. LPA Ivey Canady 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. 1 resident is present in the facility today and 5 residents are at day program.

Administrator Certificate #6015795735 expires on 8/1/2024 and is assigned to Kanisha A Allen.

The facility has submitted a Infection Control plan. The facility has one main screening entry point, and an area for visits. The facility fire alarms, fire extinguisher (05/2023) 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 Ivey Canady also reviewed 2 employee files and 2 resident files, and all the files were up to date.

LPA requested and received copies of current application for city permit for renovation of garage, regarding fire clearance addressed in NCC meeting dated 8/04/2023.

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: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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