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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701125
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:09:20 PM

Document Has Been Signed on 02/16/2022 01:09 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:CARILLO HOME CARE LLCFACILITY NUMBER:
342701125
ADMINISTRATOR:CARILLO, CRISTOPHERFACILITY TYPE:
735
ADDRESS:8936 MEADOWSPRING DRIVETELEPHONE:
(916) 684-2146
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
02/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (s) (LPA) Jamie Ivey Canady and Victoria Brown arrived at the the facility unannounced on 02/16/20222 at 11:45am and met with Christopher Carillo, applicant/administrator and Antoniette Astorga Administrator, stated the purpose of the visit. LPAs proceeded to conduct a Pre-Licensing Inspection. The home will be licensed for a capacity of 6 non ambulatory residents. Administrator certificate expires 11/13/2023.

The team toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The team observed there are 5 residents at this time.
The team observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, and laundry area. The team observed knives/sharps area to be locked. The team observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 120.*F is within the required range of 105-120*F. The temperature inside the facility measured at 73*F which is within the required range of 68-85*F. LPAs observed area where food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.
The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The team observed centrally stored medications area to be locked. The team observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility has a pull alarm system. Facility has central heating and air. The team observed the area where the staff and resident files will be locked and readily available for review.
On the facility fire inspection dated 12/14/2021, Bedrooms #1, #2, and #3 shall only be used by ambulatory and nonambulatory residents and bedroom labeled #4 shall only be used by staff.
Component III conducted - Licensure pending.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. An exit interview was conducted with Christopher Carillo and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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