<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920017
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:58:51 PM

Document Has Been Signed on 06/29/2023 03:58 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:ILLINOIS HOME, LLCFACILITY NUMBER:
345920017
ADMINISTRATOR:SAMSON, DEXTER C.FACILITY TYPE:
737
ADDRESS:5035 ILLINOIS AVETELEPHONE:
(916) 206-9433
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 4CENSUS: 4DATE:
06/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Administrator: Dexter SamsonTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/29/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Pre-Licensing Inspection. This facility is undergoing a change-of-ownership. LPA met with Facility Representatives, Susana Magana and Marie Rivera . This facility has a fire clearance for 4 non-ambulatory.

LPA toured and inspected the indoor and outdoor premises of the facility with Facility Representatives to ensure there are no health and safety concerns. Indoor and outdoor passageways were free of obstruction. LPA observed the common areas, bedrooms, bathrooms, medication room, laundry room, garage, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed fire detectors and carbon monoxide present at the facility. Bathrooms are clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. LPA observed knives/ sharps area were locked and inaccessible to clients in care. Toxic and cleaning supplies locked in the laundry room and garage. The hot water temperature was measured in the kitchen at 111 degrees Fahrenheit. LPA observed a total of 4 fire extinguishers serviced on 06/26/2023.

LPA went over Component III with Administrator. LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and report provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 1