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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:11:12 AM

Document Has Been Signed on 10/30/2023 11:11 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEOPLE'S CARE KEYESPORT WAYFACILITY NUMBER:
342700203
ADMINISTRATOR:AMANDA BRITTFACILITY TYPE:
735
ADDRESS:8317 KEYESPORT WAYTELEPHONE:
(909) 342-7163
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kizzy Thorn, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Monday October 30, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed client (4) and staff (5) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility has PPE, covid tests, and emergency food and water. Facility is clean and well maintained.

LPA Parks, John O'Brien District Manager, Administrator Kizzy toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms, kitchen, bathrooms, and backyard. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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