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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:21:04 PM


Document Has Been Signed on 09/21/2022 03:21 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:CA CARING HANDSFACILITY NUMBER:
342701191
ADMINISTRATOR:KHAN, SHAHBAZFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
09/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shahbaz KhanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Pre-licensing visit on 09/21/2022 with facility Administrator Shahbaz Khan. LPA arrived at facility at 1:00 pm and stated the purpose of the visit.

Administrator accompanied LPA on facility tour. As of today, current census is 5 residents of which 1 are Hospice, 2 are ambulatory, 2 are non-ambulatory, and 1 is bedridden. The facility is a 6 bedroom, 2 bath house with a living room, dining room, kitchen, and second living room, and laundry room. Residents have access to all areas except the garage. There were 2 of 6 staff present in the facility who were observed with criminal record clearance and associated in the Licensing Information System.
Upon entry, LPA’s temperature was taken, and LPA Campbell was asked to sign the visitor log. LPA toured the facility. Residents were observed in the family activity room and bedrooms. LPA measured the hot water in the bathroom faucet to be at 106 degrees Fahrenheit in bathroom. The thermostat was set at 75 degrees Fahrenheit for a comfortable temperature. Observed kitchen was in good condition with properly stored perishable and non-perishable foods. Knives were secured in a locked drawer.
Observed medications locked and properly stored. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in place in kitchen and fully charged. The last date the fire extinguisher was inspected was 10/19/2022.

No deficiencies were observed during today’s pre-licensing inspection. Component III was waived because Licensee has already been licensed for a prior facility. Exit interview conducted with Licensee and a copy of this report was printed on site. Administrator and Licensee have satisfied all requirements in accordance with title 22, California Code of Regulations.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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