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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920001
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:36:40 PM


Document Has Been Signed on 04/09/2024 04:36 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:CARMICHAEL ESTATES NO. 2FACILITY NUMBER:
345920001
ADMINISTRATOR:MCFADDEN, REBECCAFACILITY TYPE:
740
ADDRESS:5220 EL CAMINO AVE.TELEPHONE:
(406) 533-8373
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rebecca McFaddenTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a 1-year annual inspection utilizing the full CARE tool. LPA met with Administrator, Rebecca McFadden, and explained the purpose of the visit.

LPA and Administrator toured the interior of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, kitchen and dining.

During annual inspection, based on LIC 999 FACILITY SKETCH provided, LPA observed two residents to be in Room 1, two residents to be in Room 2, Room 3 was occupied as a staff room, Room 4 was utilized as a private room, and Staff Room was occupied by R5. Staff Room does not have a clearance for non-ambulatory status. LPA requested a copy of R5's LIC 602.

LPA informed Administrator LIC 200 and updated facility sketch is to be submitted to LPA Yang for a new fire inspection request.

File review was unable to be completed today. A case management- annual continuation visit will be conducted to complete annual inspection along with file review.

Deficiencies cited.

Exit interview conducted. Report copy and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/09/2024 04:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CARMICHAEL ESTATES NO. 2
FACILITY NUMBER: 345920001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Nonambulatory persons. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed R1 and R2 to be residing in Room 1 and R3 and R4 to be residing in Room 2 when approved for one only, and R5 to be residing in a staff room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Licensee is to notify responsible party and obtain consent for R1, R2, R3, R4 and R5 room change.
R5 is to be relocated to a fire clearance approved room and/or is to be relocated.
Licensee is to submit proof of correction to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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