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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701099
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:19:53 PM

Document Has Been Signed on 05/06/2022 12:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CAROLYN MITCHELL'S LOVING CARE HOMEFACILITY NUMBER:
342701099
ADMINISTRATOR:MITCHELL, KASSIAFACILITY TYPE:
740
ADDRESS:7556 COSGROVE WAYTELEPHONE:
(916) 919-4590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 0DATE:
05/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kassia Mitchell, Applicant/Administrator
Patrick Cain, Co Administrator		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-licensing visit on 5/6/2022 at 10:30 AM. LPA met with Kassia Mitchell, Applicant and stated the purpose of today’s visit. The facility will be licensed for a capacity of 6 non-ambulatory residents.

Applicant, Kassia Mitchell holds a current Admin certificate # 6020161740 which will expire on 09/05/2022. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.

LPA observed rooms to have required furniture. LPA observed there were no residents in care at this time. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.3*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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: CAROLYN MITCHELL'S LOVING CARE HOME
FACILITY NUMBER: 342701099
VISIT DATE: 05/06/2022
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Based on a review of this facility during this Prelicensing visit, it was determined that this facility was found to be in compliance at this time. LPA discovered that the facility designated Administrator Kassia Mitchell and Patrick Cain has completed Component III before and will therefore waive this requirement.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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