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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700945
Report Date: 10/15/2021
Date Signed: 10/15/2021 11:39:35 AM

Document Has Been Signed on 10/15/2021 11:39 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WELLCARE HOMES 3FACILITY NUMBER:
342700945
ADMINISTRATOR:HERNANDEZ, ROBERT VICTORFACILITY TYPE:
737
ADDRESS:10799 SIMMERHORN RD.TELEPHONE:
(916) 230-4087
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 0DATE:
10/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Robert HernandezTIME COMPLETED:
12:00 PM
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On 10/15/2021, Licensing Program Analyst (LPA) Mohamed Filouane conducted a pre-licensing inspection with Administrator Robert Hernandez. LPA had his temperature checked at the entrance of the facility, questioned for any COVID-19 symptoms, and then was allowed entrance. LPA explained the purpose of the visit and received updated documents from the Administrator.

At approximately 10:10 AM, LPA Filouane toured the one floor facility with the Administrator and two staff members present in the facility. The physical plant was consistent with the submitted facility floor plan and had the COVID-19 health and safety signage. The garage shall be used to store restroom essentials. The washing machines and essential cleaning solutions were in their own locked storage area. The facility also included a storage area of games and activities for future clients. No obstructions blocking indoor and outdoor passageways observed. No pools or bodies of water observed. The facility's kitchen was free of debris. Knives and additional cleaning solutions were locked. At 10:20 AM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris and fenced. At 10:15AM, LPA toured the staff room, which was its own restroom. LPA also observed the locked medication room.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current, last inspected in September of 2021. The facility's first aid kit included the required tweezers, scissors, and a thermometer. The facility's PPE supply was presented to the LPA as sufficient. The facility adhered to the seven-day non-perishable and two-day perishable food supply.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WELLCARE HOMES 3
FACILITY NUMBER: 342700945
VISIT DATE: 10/15/2021
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The facility is equipped with a fire alarm system and a sprinkler system. The facility also submitted their COVID-19 Epidemic Outbreak Mitigation Plan through email as well as handed LPA Filouane a copy during this visit. LPA also reviewed a packet of documents related to the Administrator's qualifications, including the Administrator Certification Program completion and additional files such as personnel record and criminal record statement. Following completion of the tour and then of writing this report, component III was reviewed with the Administrator.

As a result of today's inspection, the facility meets physical plant requirements of California Code of Regulations, Title 22. Licensure is recommended, pending final approval from the Centralized Applications Bureau.

No deficiencies cited. This report was discussed with the Administrator and a copy was provided through email.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
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