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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700731
Report Date: 01/06/2024
Date Signed: 01/06/2024 03:15:22 PM


Document Has Been Signed on 01/06/2024 03:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/06/2024 03:12 PM

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

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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection visit. LPA met with direct care staff and explained the purpose of the visit. Direct care staff assisted LPA for inspection visit on today's date. Administrator Certificate #6065976740 expires 2/18/2025.

LPA inspected the physical plant including, but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor and clean. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA observed an The hot water temperature was measured at 109.3*F in kitchen sink and is within the required range of 105-120*F. The temperature inside the facility measured at 75*F which was within the required range of 68-85*F. LPA observed sufficient seven day non-perishable and two day perishable food supplies.
The facility smoke and carbon detectors are in good repair. Fire extinguishers last inspected on 1/4/2024. The facility has a first aid kit, and the medications are stored in a locked cabinet. LPA toured the exterior of the facility.

LPA reviewed three resident files and two staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents shall be submitted to LPA Wallace by 01/19/2024:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, and Proof of Current Liability Insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited during this visit.
Exit interview held with direct care staff. A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
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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