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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701125
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:18:08 PM

Document Has Been Signed on 03/20/2023 12:18 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: 2DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Chris CarilloTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced for an annual inspection visit. LPAs Moleski and Lund met with facility administrator Chris Carillo and explained the purpose of the visit.

LPAs Moleski and Lund reviewed resident files for R1 and R2 and staff files for S1 and S2. No deficiencies were observed.

LPAs Moleski and Lund toured the facility with Carillo and observed the common areas, dining areas, bedrooms, kitchen and backyard. An adequate two-day supply of perishable food and a seven-day supply of nonperishable food was observed. Furniture and furnishings were adequate to meet the needs of residents. A tour of resident bedrooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents.

Medication storage, located in a closet, was observed to be locked and made inaccessible to residents. A first aid kit was observed to be present and contained all of the required components at this time. An up-to-date fire extinguisher was observed. Working smoke/carbon monoxide detectors were observed.

A tour of the resident restrooms was conducted. Furniture and furnishings were sufficient to meet the needs of the residents. Water temperature was measured and was within the required range of 105 degrees to 120 degrees. The temperature of the facility was within the required range of 68 and 85 degrees. Linen cabinets were reviewed. Linens, towels, and all items intended for resident use were observed to be sufficient and able to meet the needs of the residents at this time.

No deficiencies were cited during this visit. LPAs Moleski and Lund conducted an exit interview and a copy of this report was left with caregiver Marie Rondilla.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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