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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003012
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:26:22 PM


Document Has Been Signed on 11/30/2023 05:26 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:
(916) 514-0678
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
11/30/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Persida Pop, Administrator TIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required post-licensing insepction. LPA met Persida Pop, Administrator, and explained purpose of inspection. Also present were caregivers, Stephanie Ferroni and Tyiesha Leslie. The facility was licensed on/around 7/3/23 for (6) non-ambulatory residents and has an approved hospice waiver for (4). Currently, there are (6) residents and (1) resident receives hospice care.

LPA and Administrator toured the interior and exterior of the facility and observed it to be clean, in good repair, to have sufficient furniture and lighting, and the bathrooms to have the necessary grab bars, non-skid flooring, and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. Sharps are locked in the kitchen, medications in the medication cart and toxins in the laundry area. LPA observed the inside temperature to be 72*F. Fire extinguisher was last serviced on 12/14/22 and doors have alarms. LPA observed a complete First Aid kit. PPE and paper supplies. All smoke/monoxide alarms are functioning. Water temperature measured 110*F in the bathroom. Complete First Aid kit on site.

LPA observed various required postings. Administrator to post Theft & Loss Policy. (4) resident binders were reviewed and found to be organized and contain current documentation. (4) staff files were also reviewed and found to be organized, complete and contain current training documentation, including First Aid/CPR. Staff to ensure they have completed all required training as part of initial or ongoing training. All staff are fingerprint cleared and associated.

A copy of liability insurance policy was previously provided to the Department.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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