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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700925
Report Date: 10/26/2023
Date Signed: 10/26/2023 01:38:38 PM


Document Has Been Signed on 10/26/2023 01:38 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:VILLA NATOMAS ELDERLY CARE LLCFACILITY NUMBER:
342700925
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:540 ALCANTAR CIRTELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:6CENSUS: 6DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Barbara Williams, CaregiverTIME COMPLETED:
01:45 PM
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On October 26, 2023 at 11:00am Licensing Program Analyst (LPA) De Anna Williams-Lyons met with Barbara Williams, Caregiver, to conduct a required annual inspection. Licensee was unavailable. Administrator's certificate expires 11/24/2023.
LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. LPA observed a table in the dining area. Plates and utensils were observed to be in place. Knives are observed to be locked in the kitchen. Dishwasher, stove, refrigerator, and microwave all present and working. This facility has a fire clearance. The facility also has a fully charged fire extinguisher and functioning, smoke alarms/carbon monoxide detector and all exit doors have sound alarms. Storage and lighting were adequate in the home. All bedrooms were observed to have furniture as required by Title 22 Regulations. The facility has Six bedrooms were observed, with single occupancy. Bathrooms were observed to be in good repair. Adequate linens such as sheets, blankets, etc. were observed. Cleaning supplies and toxins were found to be locked. Medications was locked in a cabinet in the kitchen. Water temperature was measured at 105 degrees. First aid kit was present and included the required scissors, tweezers, thermometer and guide. The living room was furnished. Washer and dryer is in place and ready for use. There are no pools or bodies of water on the premises. LPA observed shaded areas in the backyard.

LPA reviewed 2 files and 2 staff files. All files had the required update documents.

Barbara and LPA completed the infectious Control questionnaire with no problems or issues.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than November 26, 2023.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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