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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701125
Report Date: 12/05/2022
Date Signed: 12/05/2022 12:40:12 PM

Document Has Been Signed on 12/05/2022 12:40 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 HOMECARE LLCFACILITY NUMBER:
342701125
ADMINISTRATOR:CARILLO, CRISTOPHERFACILITY TYPE:
735
ADDRESS:8936 MEADOWSPRING DRIVETELEPHONE:
(916) 684-2146
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
12/05/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Christopher Carillo - AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Post Licensing Inspection Visit. LPA explained purpose of the visit to administrator. The home will be licensed for a capacity of 6 non -ambulatory residents. Administrator certificate expires 11/13/2023.

LPA and administrator inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, and laundry area. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 115.3.*F is within the required range of 105-120*F. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F. LPA 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 is complete. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s) were last inspected 9/20/2022. Smoke and carbon monoxide detector(s) are current in the home. Facility has a pull alarm system. Facility has central heating and air. Bedrooms #1, #2, and #3 shall only be used by ambulatory and non-ambulatory residents and bedroom labeled #4 shall only be used by staff.

LPA reviewed five (5) resident files and three (3) staff files. A review of staff records indicates that all facility staff & other individuals who require caregiver background checks are fingerprint cleared and to the facility. LPA verified staff training for staff file reviews and all 3 staff have current First Aid Certificates.

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 administrator and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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