<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 05/29/2024
Date Signed: 05/30/2024 07:32:56 AM


Document Has Been Signed on 05/30/2024 07:32 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2024 07:31 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

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection. LPA met with Administrator and explained the purpose of the visit. Administrator certificate expires on 7/15/2024.

This facility is a single story building licensed to serve ten (10) non-ambulatory residents. LPA and administrator toured the physical plant including but not limited to resident bedrooms, resident bathrooms, dining room, patio, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.
LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 113.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers; smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 12/11/2023. Fire drill conducted on 3/29/2024. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents.

LPA reviewed five resident files and three staff files, including criminal record clearances. A review of staff records indicates that all staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following updated documents for community care licensing to be submitted via email by June 6, 2024: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance with expiration date. ruth.wallace@dss.ca.gov
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today.
Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1