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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701125
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:44:29 PM

Document Has Been Signed on 10/05/2023 03:44 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:
10/05/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Cris CarilloTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a plan of correction visit. LPA Moleski spoke with facility administrator Cris Carillo and explained the purpose of the visit.

LPA Moleski observed repairs made to two resident bedroom windowsills. Cris agreed to have an assessment done to determine if mold is present in the facility by October 19, 2023.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Carillo.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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