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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 06/14/2024
Date Signed: 06/14/2024 02:00:58 PM


Document Has Been Signed on 06/14/2024 02:00 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CA CARING HANDSFACILITY NUMBER:
342701191
ADMINISTRATOR:MICHAEL JANKOWSKIFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Michael JankowskiTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent visit on 6/14/24 at 12:15pm. LPA was met by Michael Jankowski, Administrator and stated the purpose of the visit. LPA observed a electrical outlet with a missing cover. Michael Jankowski took a photo and indicated it will be replaced today.

Based on the confirmation and observation of both the Administrator and LPA the preponderance of evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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Document Has Been Signed on 06/14/2024 02:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CA CARING HANDS
FACILITY NUMBER: 342701191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation
The facility shall be ...safe...and in good repair at all times...for the safety and well-being of residents, employees and visitors.
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Licensee/Administrator shall ensure the cover of the electrical wall outlet is replaced. Confirmation of completion shall be faxed to the office by POC due date.
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This requirement is not met as evidenced by: Based on observation of Administrator and LPA confirming the cover was missing. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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