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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701321
Report Date: 04/22/2024
Date Signed: 04/22/2024 09:21:39 PM


Document Has Been Signed on 04/22/2024 09:21 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:ST. MARTIN'S CARE HOMEFACILITY NUMBER:
342701321
ADMINISTRATOR:RODIL, MARTINFACILITY TYPE:
740
ADDRESS:10720 BECLAN DRIVETELEPHONE:
(916) 934-9327
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 1DATE:
04/22/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Martin RodilTIME COMPLETED:
06:30 PM
NARRATIVE
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On 4/22/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a Post Licensing inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Martin (Marty) Rodil and a brief interview followed.

LPA requested the Certificate of Insurance for liability and reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection.

LPA reviewed the resident file for the one resident in care at the present time. LPA provided technical assistance regarding the LIC 602, and LIC 625. LPA reviewed Employee file for Licensee/Administrator and provided technical assistance on record keeping for new hires.

LPA observed the following posted in the living room of the facility: See Something Say Something complaint poster, Reporting Requirements, Resident Bill of rights, Ombudsman Poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

According to the California Code of Regulations, Title 22, there were no deficiencies cited during today's visit.
Due to technical difficulties, this LPA was unable to provide a printed copy of this report at the end of the visit, however a handwritten report was left on site to document the inspection and a copy of this report will be emailed within 24 hours.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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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