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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 12/20/2022
Date Signed: 12/20/2022 11:26:52 AM


Document Has Been Signed on 12/20/2022 11:26 AM - 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:
12/20/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janice Rivera, CaregiverTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the care home today to conduct a post-licensing visit. LPA was greeted by Janice Rivera and explained the purpose of the visit. The Care home currently has 5 residents in care. There are 6 rooms available for residents in all.

A complete tour of the care home was conducted on this date which included the kitchen, bedrooms, bathrooms and the backyard and perimeter of the home. There is a sufficient amount of food supply on hand and food is being properly stored. Knives, sharp objects, toxins and cleaning supplies are stored separately and inaccessible to the residents.

LPA observed sufficient staffing on hand to meet the residents needs, and medications are locked and secured and are being administered to the residents as well. Residents bedrooms and bathrooms are being maintained and the care home is at a comfortable temperature of 82 degrees Fahrenheit.

Resident files have been created for each individual resident.

No deficiencies cited during todays visit.


Exit interview conducted. Report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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