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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002929
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:12:32 PM


Document Has Been Signed on 10/05/2023 03:12 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:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kassie HowellTIME COMPLETED:
03:15 PM
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On 10/5/2023 at 1:45PM, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPAs met with caregiver, Kassie Howell, and explained the purpose of the visit.

Facility is licensed for six bedridden and hospice waiver for six. Facility is found to be in compliance to licensure. During today's inspection, LPAs and Caregiver conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six private residents room, four bathroom, kitchen, backyard, storage area, and common areas. LPAs observed the fire extinguisher to be last serviced on October 14, 2022. LPAs informed Caregiver that fire extinguisher should be serviced annually to ensure it is in good condition. LPAs observed sharps, toxins, and medications to be locked and secured.

LPAs observed five out of six residents LIC 602 Physician's Report to be dated in 2022. LPAs informed caregiver that LIC 602s should be updated annually to ensure no change in conditions for residents in care. Additionally, LPAs provided California Code Regulation 87506 Resident Records to caregiver as reference.

LPAs and Caregiver completed the care tool together and found the facility to be in compliance.

Exit interview conducted 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: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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