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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701303
Report Date: 09/19/2024
Date Signed: 09/19/2024 12:40:20 PM

Document Has Been Signed on 09/19/2024 12:40 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:
(916) 476-3170
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Novette MacaliboTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 9/19/24 at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual inspection visit. LPA met with Novette Macalibo, Administrator (ADM), and stated the purpose of this visit. Clients in care were out in the community during this visit. Facility currently serves 4 non-ambulatory adult individuals.

LPA and ADM inspected the physical plant of the facility. The facility is a one-story home located in a residential neighborhood. Front yard and backyard were observed to be clean and free of obstructions. LPA observed outdoor furniture for clients' use. Fences and gates were observed to be in good repair. LPA inspected the shut-off valves and found to be in good repair.

Four client bedrooms were inspected and observed to be clean and large enough space to accommodate client belongings. Each client bedrooms have their own exit to the outside. Facility has 4 bathrooms for client use and observed to be clean and in good repair. The kitchen and pantry were inspected and observed to be sanitized and in good repair. Food supplies were stored properly. Facility maintains an adequate amount of food supply with 2-day perishables and 7-day nonperishables. Smoke detectors/carbon monoxide monitor combo were observed and tested and were found to be operable during this visit. Sharps, toxins and medications were observed to be locked and inaccessible to clients in care. Facility was observed to have adequate supply of linens for clients. Fire extinguisher was observed at the kitchen area near the stove and were last serviced on 4/11/24. Room temperature was at 75*F and hot water temperature was at 106*F in the one bathroom located in the hallway of the resident bedrooms. Fireplace was observed to be screened and inaccessible to clients.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ND CARE HOME
FACILITY NUMBER: 342701303
VISIT DATE: 09/19/2024
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LPA reviewed 4 of 4 client records and found to be in compliance at this time. LPA reviewed and counted, with ADM, 2 of 4 clients' P&I money and found to be accurate. LPA reviewed 2 of 4 resident medications and found to be in compliance. LPA reviewed 4 personnel records and were found to be in compliance at this time with current 1st Aid/CPR certificates, Behavioral Management certificates and background clearances. Facility conducts monthly emergency drills with last drill was conducted on 9/6/24.

LPA requested copies of the following documents during this visit: current Liability Insurance Certificate, Surety Bond, LIC500, LIC308.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed or cited

Exit interview held with ADM, and a copy of this report was provided.
















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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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