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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003015
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:37:03 PM


Document Has Been Signed on 03/06/2024 12:37 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 4FACILITY NUMBER:
345003015
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:4401 LITTLE BROOK CTTELEPHONE:
(916) 500-4512
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 0DATE:
03/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Persida Pop, LicenseeTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Michael Hood met with applicant, Persida Pop, to conduct a Pre- Licensing visit. The facility has a fire clearance for 6 ambulatory residents with a hospice waiver for 4 residents. Applicant holds a current administrator certificate (#7002556740 with an expiration date of 11/12/2025).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 105.5 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to clients. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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