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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701317
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:04:03 AM

Document Has Been Signed on 01/28/2025 10:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TAMBOR HOMEFACILITY NUMBER:
342701317
ADMINISTRATOR/
DIRECTOR:		VERGARA, RICHARD CARLSONFACILITY TYPE:
735
ADDRESS:8458 TAMBOR WAYTELEPHONE:
(510) 825-5851
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 3CENSUS: 0DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Richard VergaraTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct an annual inspection. LPA Moleski met with facility administrator Richard Vergara and explained the purpose of the visit.

No clients are currently in care. No staff or client files were available for review, and interviews with clients and/or staff were not possible.

LPA Moleski toured the facility with Vergara and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is 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. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

No deficiencies were cited during this visit. 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: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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