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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701303
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:02:20 PM

Document Has Been Signed on 05/03/2024 12:02 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:ND CARE HOMEFACILITY NUMBER:
342701303
ADMINISTRATOR/
DIRECTOR:
MACALIBO, NOVETTE DFACILITY TYPE:
735
ADDRESS:2112 MCGREGOR DRIVETELEPHONE:
(719) 200-9105
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 2DATE:
05/03/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Novette MacaliboTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Post Licensing visit on 5/3/24 at 9:00am. Administrator Certificate expired 4/14/24, however, LPA observed a letter from Community Care Licensing indicating renewal documentation was received.

LPA met with Novette Macalibo, Administrator and MariaBernadette Carrera, Designee regarding the purpose of todays visit. The facility is licensed for a capacity of 4 non-ambulatory residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The most recent emergency drill was conducted on 4/12/24.

The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.9*F which is within the required range of 105-120*F. LPA observed pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.


Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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