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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000118
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:06:18 PM


Document Has Been Signed on 08/15/2023 03:06 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:NUNEZ CARE HOME #2FACILITY NUMBER:
347000118
ADMINISTRATOR:NUNEZ, LEONIL AND RUBYFACILITY TYPE:
740
ADDRESS:8005 35TH AVENUETELEPHONE:
(916) 383-1437
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:3CENSUS: 3DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Salvacion SantosTIME COMPLETED:
03:15 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 08/15/2023 at 12:05 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee knocked on the door and no one was home. LPA Lee called administrator, Leonil Nunez, (916) 753-7094 and spoke to administrator. Administrator stated that administrator will send a staff shortly. Care staff Salvacion Santos arrived 33 minutes later. Administrator arrived approximately two hours later and joined the annual inspection. Care staff Salvacion Santos assisted with today’s visit. Administrator certificate # is 6002516735 and will expire on 11/17/2023. The current census is 3 with 2 facility staff.

This facility is a single story building licensed to serve three (3) ambulatory only developmentally disable clients. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 116.3 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 03/14/2023. The last fire drill was conducted on 07/04/2023. LPA Lee observed the facility has a has a public telephone in the dinning area.

The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: NUNEZ CARE HOME #2
FACILITY NUMBER: 347000118
VISIT DATE: 08/15/2023
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
26
27
28
29
30
31
32
 LPA Lee reviewed 3 out of 3 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 3 out of 3 client files and 5 out of 6 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 08/18/2023 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2