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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920046
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:31:23 PM


Document Has Been Signed on 09/29/2023 12:31 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:SIGNATURE LIVING ON WINDING WAY IIIFACILITY NUMBER:
345920046
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6264 WINDING WAYTELEPHONE:
(916) 952-4348
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
09/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Edgar EneroTIME COMPLETED:
12:35 PM
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On 9/29/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived announced at the facility to conduct a pre-licensing inspection. LPAs met with Licensee, Edgar Enero, and explained the purpose of the visit.

During today's visit, LPAs and Licensee conducted a tour of the interior and exterior of the facility. LPAs observed the facility to have the mandated posters on the wall. LPAs observed fire extinguisher to be recently served on 08/01/2023. LPAs observed six private residents rooms, two bathrooms, laundry room, kitchen, backyard and the common areas. LPAs observed the facility to have the mandated furnishing in resident's room. LPAs observed the locked cabinets which is designated for medication, toxins and sharps. In areas toured, no immediate health and safety violations were observed. LPAs observed the facility to be ready for licensure.

Comp III was waived as Administrator and Licensee are familiar with the Department's expectations as Administrator has multiple residential facilities with CCLD.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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