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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920046
Report Date: 08/05/2024
Date Signed: 08/05/2024 02:38:14 PM

Document Has Been Signed on 08/05/2024 02:38 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/
DIRECTOR:		AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6264 WINDING WAYTELEPHONE:
(916) 952-4348
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Scott Afable and Placida DeveraTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 8/5/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with Staff, Placida De Vera, and explained the purpose of the visit. Staff then contacted Administrator who stated inspection can be conducted with Staff until Administrator's arrival.

Today's visit, there are five residents in care. Facility is licensed for six non-ambulatory residents with hospice waiver of six.

During today's inspection, LPA and Staff conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six residents rooms, two bathroom, laundry room, kitchen, backyard and the common areas. Areas toured, no deficiencies observed as LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA observed temperature to be at 67*. LPA observed ample supply of linens. LPA observed facility to have sharps, toxins and medications to be locked and secured.

LPA conducted a file review for two personnel and five residents.

Administrator and LPA discussed ensuring all facility staff from other sister facilities are associated to the facility in case of emergency staff fill-ins.

LPA is requesting LIC 500 and liability insurance to be emailed to LPA by end of week 8/9/2024.

As a result of today's visit, no deficiencies cited.

Exit interview and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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