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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700506
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:02:49 PM


Document Has Been Signed on 08/23/2023 01:02 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Caregiver Alegrine NacarTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on Monday 8/23/23 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (3) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. All required posting were observed. Staff training contained the required initial training.

LPA and Caregiver Alegrine Nacar toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area.The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department.

Exit interview conducted. A copy of this report was printed and given to Caregiver.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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