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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700591
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:40:23 PM


Document Has Been Signed on 10/20/2022 05:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:VILLAVERT CARE HOME FOR ADULTS INCFACILITY NUMBER:
342700591
ADMINISTRATOR:VILLAVERT, JULIE ANNFACILITY TYPE:
735
ADDRESS:4967 J PARKWAYTELEPHONE:
(916) 505-8184
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 3DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julie Ann VillavertTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Jamie Ivey Canady arrived unannounced to conduct a Required Annual Inspection on 10/20/2022 at 9:00 am. LPA were allowed entry into the building. LPA met with Julie Ann Villavert, administrator regarding today's visit. Three residents were present during this visit and three residents are reported to be at day program.
Administrator certificate expires 11/25/2022 #6050078735.
LPA toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA observed, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 72 *F which is within the required range of 68-85*F. The hot water temperature was measured at 118*F which is within the required range of 105-120*F. 
The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke detectors and pull alarm system. Facility has central heating and air.
At 9:55 am two resident files and two staff files were reviewed during this visit. Staff files contain current background clearances. Resident IPP plans current as of 8/21/2022.

Per the California Code of Regulations, Title 22 no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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