<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700945
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:20:30 AM

Document Has Been Signed on 03/22/2022 11:20 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: 2DATE:
03/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Robert Hernandez, AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/22/2022 at 9:20 AM, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a Post-Licensing inspection. LPA met with Administrator, Robert Hernandez and explained the purpose of today’s inspection. Administrator holds a certificate #6041381735 that expires on 05/26/2022. LPA was allowed entry into the facility that is licensed to serve a total capacity of 4 ambulatory clients, which 2 may be non-ambulatory.

LPA observed 2 clients and 6 staff members present at the facility.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature in the client's shared bathroom measured at 105.8 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on September 10, 2021. First aid kit was observed to be complete. Fire drill was last conducted on 02/28/2022. Emergency Disaster Plan last posted 01/22/2022. LPA observed completed mitigation plan. LPA observed vehicle registration has been updated. LPA reviewed 2 resident files/medications, and 3 staff records. LPA reviewed 1 clients' P & I money. Based on Administrators interview, facility has not received P & I money for 1 client.

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1