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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700777
Report Date: 06/29/2023
Date Signed: 07/05/2023 08:56:37 AM


Document Has Been Signed on 07/05/2023 08:56 AM - 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 WAY IIFACILITY NUMBER:
342700777
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6270 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Scott AfableTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on 06/29/2023 to conduct a Required-1 Year Inspection utilizing the full CARE tool. LPA met with staff, Nomar Sanchez and explained the purpose of the visit. Administrator, Scott Afable, arrived to the facility shortly after the facility tour.

LPA and staff toured the interior and exterior of the facility together with facility staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA observed Administrator Certificate #6032256740 to be current with expiration date of 8/24/2024. LPA observed sharps and toxins to be located and secured. LPA observed fire extinguisher to be last serviced on 05/09/2023. LPA observed facility to have 2+ days of perishables and 7+ days of nonperishable food. LPA observed the pool gate to be locked and secured. LPA reminded Administrator PUB 475 poster must be resized to 20x26.

LPA and Administrator completed the CARE tool and found the facility to be compliance at this time.

As a result of today's inspection, no deficiencies are being cited.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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