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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:19:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CARMEN'S CARE HOMEFACILITY NUMBER:
347000923
ADMINISTRATOR:NAVARRO, CARMENFACILITY TYPE:
740
ADDRESS:5392 MEADOW PARK WAYTELEPHONE:
(916) 427-1828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
01/04/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carmen NavarroTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensed Program Analyst (LPA)s Jamie Ivey Canady and Victoria Brown arrived unannounced to conduct a required annual visit on 01/04/2022 at 10:30 am. LPAs met with Carmen Navarro administrator and stated the purpose of the visit.

Administrator Certificate expires 12/14/22. The facility is licensed for a capacity of 6 residents.

LPAs toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed residents during this visit. LPAs observed 2-day perishables but did not observe 7-day non-perishables.

The temperature inside the facility was observed to be at 75* F which is within the required range of 68-85*F. The hot water temperature was measured at 130.5*F which is not within the required range of 105-120*F. Licensee/Administrator turned down the hot water heater and it was retested and measured at 105*F during this visit.

LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed fire drill is conducted monthly. LPA observed Designation Of Facility Responsibility LIC308. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2022
Section Cited

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General Food Service Requirements
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premise
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This requirement is not met as evidenced by: There was not a sufficient amount of non-perishables
Based on observation of food items in the cabinets with the administrator,it was confirmed there was not enough supply of non-perishables during this visit. This poses an immediate health and safety risk to residents in care.
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Type A
01/05/2022
Section Cited

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Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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This requirement is not met as evidenced by: The temperature of the hot water was measured at 130.5*F
Based on observation and LPA measured the hot water to be above 120*F during this visit. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923
VISIT DATE: 01/04/2022
NARRATIVE
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Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Personnel Report (LIC500)
Administrator Certificate-Updated

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held with Carmen Navarro, Licensee/Administrator. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3