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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700775
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:07:06 PM


Document Has Been Signed on 09/11/2023 04:07 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:FOLSOM CAREFACILITY NUMBER:
342700775
ADMINISTRATOR:ABELARDO, BERYLFACILITY TYPE:
740
ADDRESS:148 STONEY HILL DRIVETELEPHONE:
(916) 983-9988
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:5CENSUS: 5DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Beryl Abelardo, AdministratorTIME COMPLETED:
02:00 PM
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On 9/11/2023 LPA Tryon visited the facility to do an annual visit. LPA met with Antonio Bilan and Administrator Beryl Abelardo.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, storage areas, yard.
The home is very clean, nicely furnished, there is plenty of space for inside activities or space outside. There are smoke detectors and carbon monoxide detectors installed, fire extinguisher is charged and up to date.
Appropriate posters are present in the entryway/hallway. All residents have private rooms. Grab bars and non-skid surfaces in bathrooms.
The home was at a comfortable temperature.
Food supplies were appropriate to meet the requirement of 2 days perishable and 7 days non-perishable. Food is properly stored.

LPA reviewed the CARE Tool with Administrator.

LPA reviewed 2 of 5 resident files and 2 staff files. Files are nicely organized and contain appropriate documents/information.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were noted at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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