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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700045
Report Date: 09/27/2023
Date Signed: 09/27/2023 10:25:58 AM

Document Has Been Signed on 09/27/2023 10:25 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:ENCAREFACILITY NUMBER:
342700045
ADMINISTRATOR:WASDYKE, GINAFACILITY TYPE:
735
ADDRESS:11041 CARMENET WAYTELEPHONE:
(916) 594-9332
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Gina WasdykeTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/27/2023 at 8:45 AM. LPA Martinez met with Gina Wasdyke 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 courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on December 11, 2023. The facility is licensed for 1 non-ambulatory client and three bedridden clients in rooms 1, 2, and 3. There are currently 4 clients who reside at this facility.

LPA Martinez toured the facility with Gina Wasdyke on 09/27/2023 at 9:45 AM.

The facility is sanitary and furnished, and the facility has a public telephone. The facility has an infection control plan and natural disaster plan. LPA Martinez reviewed employee and resident files, and the files are complete and up to date. LPA Martinez reviewed two Medication Administration Records (MAR), and the MARs were complete. The facility has a first aid kit, and medications are stored in a locked cabinet. The facility fire extinguisher is in good repair, and last fire drill was on August 29, 2023.

The facility has an area for activities, and the facility temperature measured at 70 degrees. All client bedrooms and bathrooms were sanitary and furnished. The facility has night lights throughout the facility and in bathrooms. The facility kitchen is sanitary and has an adequate food supply. In addition, the facility has emergency food and water kit. The Laundry room is clean and furnished. The exterior of the home is clear of debris, and the emergency exit door is in good repair.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.

An exit interview was held, and a copy of this report was provide to the facility at the end of the visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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