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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920025
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:21:49 AM

Document Has Been Signed on 09/28/2023 10:21 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VALDEZ CARE HOMEFACILITY NUMBER:
345920025
ADMINISTRATOR:VALDEZ, NORAFACILITY TYPE:
735
ADDRESS:8510 STORY RIDGE WAYTELEPHONE:
(408) 391-3375
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
09/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Nora ValdezTIME COMPLETED:
10:30 AM
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On 09/28/23, Licensing Program Analyst (LPA) Talwinder Bains met with applicant Nora Valdez to conduct a announced Pre- Licensing visit.

The facility has a fire clearance (05/25/23) for 3 ambulatory and 1 non ambulatory residents. Facility has no residents at this time. Applicant holds a current administrator certificate (# 6020758735 with expiration date 01/04/2024) .



LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA inspected 4 bedrooms for residents, 1 bathroom, common area, family room, kitchen, Play/games/office area , laundry area and outdoor area. Facility has no garage. LPA observed facility to be properly furnished, including appropriate bedding and lighting in the facility . Bathroom was in sanitary condition and properly maintained. This house is 2 story building and applicant clarified that only 1st floor will be used for residents and 2nd story is only for staff/owner residence use.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 residents. 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. Water temperature was observed at 112 degrees F.Licensee agrees to notify LPA once first consumer is admitted.A working telephone has been set up for residents use.

Pre-licensing passed and Component III (ARF) was completed with Nora. Facility has satisfied all requirements in accordance to Title 22, California Code of Regulations. 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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