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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 09/27/2023
Date Signed: 09/27/2023 12:53:11 PM


Document Has Been Signed on 09/27/2023 12:53 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:3CENSUS: 0DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Craig FowlerTIME COMPLETED:
11:37 AM
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility unannounced to conduct a Required 1- year annual inspection. When LPAs arrived to the facility, LPAs observed the facility to be vacant. LPAs contacted Administrator, Craig Fowler who arrived to the facility shortly afterwards.

LPAs were informed, facility has yet to be open and operating. LPAs conducted a tour of the interior and exterior of the facility to ensure the facility is in compliance to Title 22. In areas toured including but not limited to: kitchen, bathroom, four bedrooms, backyard and common areas, no immediate health and safety violation was observed.

LPAs observed the facility to have 7+ days of non-perishable food. LPAs observed fire extinguisher to be recently serviced, LPAs observed toxins, medication box and sharps to be locked and secured. LPAs observed the facility to have the required posters on the wall. LPAs observed a pool located in the exterior of the facility. LPAs advised that the fence in the backyard should be replaced with a higher fence, and locked at all times to be locked and inaccessible to future residents in care.

No resident records was reviewed as facility's census has been zero since licensure. LPAs informed Administrator that all staff should have a facility file for Licensing to inspect once operating.

LPAs requested a copy of the facility's liability insurance to be emailed to LPA Yang by Friday October 6, 2023.

Additionally, LPAs provided Administrator a copy of the California Code Regulation: 87506 Resident Records, 87412 Personnel Records, and 87355 Criminal Record Clearance.

Exit interview and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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