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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700355
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:34:52 PM

Document Has Been Signed on 01/07/2025 03:34 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:KAMIL HASSEN CARE HOMEFACILITY NUMBER:
342700355
ADMINISTRATOR/
DIRECTOR:
HASSEN, FOZIAFACILITY TYPE:
735
ADDRESS:8705 SUMMER POINTE DRTELEPHONE:
(916) 425-4622
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
01/07/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:54 PM
MET WITH:Fozai HassenTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1/7/25 Licensing Program Manager (LPM) Stephen Richardson and Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management annual continuation visit today at the facility to continue with the Annual visit initiated on 12/10/2024. LPM and LPA met initially met with staff on duty (S1) and stated the purpose of this visit. The Administrator later arrived with another staff, along with 1 client in care. Current census is 3. Upon arrival, there were 2 clients in care with 1 staff on duty (S1).

During this visit, LPM and LPA reviewed seven staff files, which included, but were not limited to, First Aid/CPR, Health Screening, and Fingerprint Clearance. No issues were noted.

A medication review was conducted for 2 out of 3 clients, including the Medication Administration Record (MAR), Centrally Stored Medication Record, and Physician's Orders. No issues were noted.

The first aid kit was reviewed and found to contain all the required items. The facility conducts monthly disaster drills, with the most recent fire drill held on 12/28/24.

The hot water temperature in the resident bathroom was measured at 116°F, and the kitchen faucet hot water temperature was measured at 120.6°F. A Technical Advisory was issued to place a warning sign at this faucet.

LPA obtained the current copies of the following documents: Personnel Record, Designation of Facility Responsibility, Liability Insurance Certificate, and Surety Bond.

No deficiencies are cited during today's visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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