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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701125
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:33:13 PM

Document Has Been Signed on 08/31/2023 12:33 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CARILLO HOMECARE LLCFACILITY NUMBER:
342701125
ADMINISTRATOR:CARILLO, CRISTOPHERFACILITY TYPE:
735
ADDRESS:8936 MEADOWSPRING DRIVETELEPHONE:
(916) 829-5768
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 4DATE:
08/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Chris CarilloTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with administrator Cristopher Carillo and explained the purpose of the visit.

LPA Moleski reviewed an annual Title 17 review conducted on 7/13/23. In the review, Alta California Regional Center (ACRC) representatives identified "water damage" and "possible mold" in two resident bedrooms. ACRC representatives also found containers of toxins on the garage floor with a "small amount of toxin left in bottles."

LPA Moleski inspected the windowsills located in two resident bedrooms. LPA Moleski observed black-colored wood rot on the sills. LPA Moleski photographed the rot. LPA Moleski inspected the facility's garage. The garage was locked at the time of this visit.

This facility is being cited per 22 CCR Section 80087(a). An exit interview was held with Carillo. Appeal rights and a copy of this report were left with Carillo.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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Document Has Been Signed on 08/31/2023 12:33 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/31/2023 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARILLO HOMECARE LLC
FACILITY NUMBER: 342701125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
80087(a)

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"(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors."

This requirement was not met as evidenced by:
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Licensee agrees to have an expert come out to the facility to assess the rot located in two resident bedrooms on the windowsills by the POC due date to determine further course of action. Licensee agrees to send LPA Moleski a written report or other proof of this assessment.
vincent.moleski@dss.ca.gov
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Based on observation of rot on two resident bedroom windowsills, the facility was not kept in good repair, which poses a poential health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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