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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 01/06/2023
Date Signed: 01/06/2023 10:32:01 AM


Document Has Been Signed on 01/06/2023 10:32 AM - 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:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR:CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:10CENSUS: 8DATE:
01/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Edna CleggTIME COMPLETED:
11:00 AM
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On 1/6/22 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Clegg Care Facility for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Edna Clegg and together conducted a tour of the home. The home is a single story home in a residential neighborhood with a capacity for 10 residents. LPA observed 7 residents currently in placement. LPA observed 7 resident bedrooms and two resident bathrooms.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 106.7 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 500 and Client Roster.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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