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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000118
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:21:49 PM


Document Has Been Signed on 09/19/2024 03:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Ferdinand SadayaTIME COMPLETED:
03:25 PM
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On 09/19/2024 at 12:33 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Ferdinand Sadaya who then called administrator Leonil Nunez. Lee explained the purpose of the visit and administrator stated that care staff can assist LPA with today’s visit. The current census is 3 with 1 facility staff.

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

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 105.2 degrees Fahrenheit in the resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA observed grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 03/20/2024. The last fire drill was conducted on 09/01/2024. LPA observed the facility has a has a public telephone in the dining room. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located under the kitchen sink and kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NUNEZ CARE HOME #2
FACILITY NUMBER: 347000118
VISIT DATE: 09/19/2024
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LPA reviewed and compared 3 out of 3 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all of the required components. LPA requested resident and staff files for review. LPA reviewed 3 out of 3 resident files and 3 staff files and they were complete. LPA 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 by 09/25/2024 end of day 5:00 PM


(1) LIC 308 Designation of Administrative Responsibility
(2) 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 this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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