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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003012
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:11:15 PM


Document Has Been Signed on 06/20/2023 12:11 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 HOME #2FACILITY NUMBER:
345003012
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:3840 DELL RDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
06/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Persida PopTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 6/20/23 to conduct a Pre-licensing referencing the CARE inspection tool. LPA met with Administrator and explained the purpose of the visit.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA advised Administrator to maintain bed rail orders when needed and repair window blinds if damaged.


Component III review is waiver as the applicant has other homes.

The facility is in significant compliance

License pending approval.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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