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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003004
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:21:01 PM


Document Has Been Signed on 09/13/2023 01:21 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/13/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 9/13/23 to conduct a Post Licensing Inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and seven (7) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 107.5 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are hard wired and operational. Fire extinguishers and first aid kit are maintained and ready for emergency use.

LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files and also reviewed two (2) staff files. Administrator has a current Administrator's Certificate #6009251740 with an expiration date of 11/11/23.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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