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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700506
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:56:49 AM


Document Has Been Signed on 08/31/2022 11:56 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:KENTFIELD ESTATES RANCH RCFEFACILITY NUMBER:
342700506
ADMINISTRATOR:SOUMAHORO, MARIAM GBATYFACILITY TYPE:
740
ADDRESS:3800 SILVER SPUR WAYTELEPHONE:
(916) 904-0027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alejrine Nacar, CaregiverTIME COMPLETED:
12:16 PM
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On August 31, 2022, Licensing Program Analyst DeAnna Williams-Lyons arrived unannounced to conduct a 1 year annual inspection. LPA met with Alejrine Nacar, Caregiver, and informed him the reason for the visit. Prior to the inspection, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Mask In addition, LPA was screened by staff upon arrival.

Alejrine and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrator certificate is valid, expiring 10/15/2022 First aid kit fully stocked and ready for emergency use. Fire extinguisher is fully charged . The home was 75 degrees F. Which is in the right temperature range.

Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food.
Exterior of the home is in good repair with no bodies of water on the premises. Medications were locked up and MARS log was current and complete.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than September 30, 2022.

Exit interview conducted and a copy of this report given to Alejrine.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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