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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701317
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:23:36 PM

Document Has Been Signed on 01/04/2024 12:23 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:TAMBOR HOMEFACILITY NUMBER:
342701317
ADMINISTRATOR:VERGARA, RICHARD CARLSONFACILITY TYPE:
735
ADDRESS:8458 TAMBOR WAYTELEPHONE:
(510) 825-5851
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 0DATE:
01/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Richard VergaraTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a prelicensing inspection. LPA Moleski met with applicant Richard Vergara and explained the purpose of the visit.

LPA Moleski reviewed application documents with Vergara and conducted Component III orientation.

LPA Moleski toured the facility with Vergara and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 125 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a locked closet for the storage of medication and knives. LPA Moleski observed locked cabinets for the storage of cleaning solutions.

LPA Moleski and Vergara observed an outlet in a prospective client bedroom which did not operate with the light switch. The overhead light did not turn on or off when the switch was flipped. LPA Moleski and Vergara observed a storage shed in the backyard which did not have a handle or lock. LPA Moleski and Vergara observed rot on the shed roof. LPA Moleski and Vergara observed that windows on the house were without screens.

Deficiencies were observed during this visit. Vergara agreed to correct the observed deficiencies by February 4, 2024. LPA Moleski will return at a later date to assess corrections. An exit interview was conducted and a copy of this report was left with Vergara.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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