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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700588
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:32:20 PM


Document Has Been Signed on 09/29/2023 04:32 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:SIGNATURE LIVING ON WINDING WAYFACILITY NUMBER:
342700588
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6258 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Placida De VeraTIME COMPLETED:
03:10 PM
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On 9/29/2023 at 12:30 PM, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1-year annual inspection utilizing the full CARE tool. LPAs met with Caregiver, Placida De Vera and Randy De Vera, and explained the purpose of the visit.

During today's inspection, LPAs observed the presence of six residents in care, two on hospice services. LPAs and Caregiver conducted a tour of the interior and exterior of the facility. In areas toured included but not limited to: six private residents room, two bathrooms, laundry room, kitchen, backyard, storage shed and common areas. LPAs observed toxins to be locked and secured. LPAs observed the facility to have ample supply of clean linen. Additionally, LPAs observed the facility to have 2+ days perishable and 7+ days of nonperishable foods. LPAs observed sharps and medications to be locked and inaccessible to residents in care. LPAs observed the exterior of the facility to be clear from tripping hazards, LPAs observed the storage shed to be locked. In areas toured, no immediate health, safety or personal rights violation was observed.

LPAs conducted a file review of five resident records and three personnel records. Based on file review, LPAs observed facility files to be complete. LPAs observed Administrator Certificate #6032256740 to be current with expiration date of 08/24/2024. LPAs observed active liability insurance, expiration date of 11/21/2023.

As a result of today's inspection, LPAs completed the CARE tool and found the facility to be in compliance to Title 22. No deficiencies cited.

Exit interview conducted and a copy of the report was left with caregiver.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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