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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000244
Report Date: 10/14/2024
Date Signed: 10/14/2024 11:16:40 AM


Document Has Been Signed on 10/14/2024 11:16 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HERJEMA CARE #3FACILITY NUMBER:
347000244
ADMINISTRATOR:POSADAS, JENIEFACILITY TYPE:
735
ADDRESS:7116 ELDER CREEK ROADTELEPHONE:
(916) 381-4735
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:6CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Jenie Posadas TIME COMPLETED:
11:30 AM
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On 10/14/2024 at 8:36 AM, Licensing Program Analysts (LPAs) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with Administrator Jenie Posadas. LPA Lee explained the purpose of today’s visit. Administrator Jenie assisted with today’s inspection. Administrator Certificate # 6023701735 expires on 01/03/2025. The current census is 5 with 1 facility staff.

This facility is a single story building licensed to served five (5) ambulatory clients. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, clients’ bathrooms, laundry room, staff room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA observed client bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA toured the kitchen and observed the facility had sufficient seven-day non-perishable food supplies and 2 days perishable food supplies. Hot water temperature was measured at 118.2 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the dining room and was last serviced on 04/10/2024. The last fire drill was conducted on 09/01/2024. LPAs observed the facility has a has a public telephone in the kitchen area. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet kept locked and inaccessible to clients. LPA observed sharp knives kept locked and inaccessible to clients. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed and compared 2 out of 5 medication administration record (MAR) along with client medications and it was all complete. LPA asked to inspect the facility’s first aid kit and it was complete. LPA requested client and staff files for review. LPAs reviewed 5 out of 5 client files and they were complete. LPA reviewed 2 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.

As a result of this annual visit, the facility is in compliance with Title 22 Regulation, and no deficiencies were cited. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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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