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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003014
Report Date: 06/09/2023
Date Signed: 06/12/2023 08:41:04 AM


Document Has Been Signed on 06/12/2023 08:41 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:LITTLE BROOK CARE HOME #3FACILITY NUMBER:
345003014
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:7300 NOB HILL DRTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
06/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Persida PopTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 6/9/23 to conduct a Pre-licensing referencing the infection control domain. 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.
Water temperature exceeded 120' near rm 2/3.


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

Facility will correct water temperatures and get bed rail orders for 2 residents. Proof of corrections will be submitted to LPA.

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: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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