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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 01/13/2023
Date Signed: 01/13/2023 11:18:06 AM


Document Has Been Signed on 01/13/2023 11:18 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
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:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Remedios SobrebenaTIME COMPLETED:
11:30 AM
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Licensed Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/13/23 at 10:00 am. LPA met with Remedios Sobrebena, Cynthia Navarro Caregivers and Carmen Navarro, Licensee/Administrator and stated the purpose of the visit. The facility is licensed for a capacity of 6 residents.

LPA 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. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73* F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0*F which is within the required range of 105-120*F. Licensee/Administrator turned down the hot water heater 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.

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, no deficiencies cited during this visit. 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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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