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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920025
Report Date: 09/12/2024
Date Signed: 09/18/2024 11:03:58 AM

Document Has Been Signed on 09/18/2024 11:03 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/
DIRECTOR:		VALDEZ, NORAFACILITY TYPE:
735
ADDRESS:8510 STORY RIDGE WAYTELEPHONE:
(408) 391-3375
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Administrator- Nora ValdezTIME VISIT/
INSPECTION COMPLETED:
11:08 AM
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On 09/18/2024, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a Required- 1 Year Inspection. LPA met with Administrator, Nora Valdez, to conduct the visit. The reason why this visit is announced is because there are currently no residents at the facility.

LPA and administrator toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, four (4) private resident bedrooms, bathroom, kitchen, laundry room and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathroom to be clean, sanitary, and in good repair. The hot water temperature was measured in the bathroom sink at 116.5 degrees Fahrenheit which is within the required range of 105 to 120 degrees
Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 07/10/24. LPA observed required Licensing posters posted throughout the facility. There are locked cabinets for toxins in the laundry room. There are locked cabinets for medications and knives in the kitchen.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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