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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001602
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:15:33 PM

Document Has Been Signed on 05/17/2024 04:15 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:KELLY ACACIO'S CARE HOMEFACILITY NUMBER:
347001602
ADMINISTRATOR/
DIRECTOR:		ACACIO, LYNDALEFACILITY TYPE:
735
ADDRESS:8333 HOLLY JILL WAYTELEPHONE:
(916) 395-9279
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 5DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kelly AcacioTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 5/17/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct Required 1 Year Annual Inspection Visit. LPA met with Licensee Kelly Acacio and explained the purpose of today’s visit.

Administrator holds certification #6021297735 and expires on 10/8/24. There are 5 clients in care.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to clients. LPA observed required furniture and lighting throughout the facility. LPA observed 2-day perishables and 7-day non-perishables. The hot water temperature was measured at 112.3*F which was within the required range of 105-120*F. The temperature inside the facility observed at 73*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. All emergency exits were clear from obstructions.

LPA requested client and staff files for review. LPA reviewed three (3) client files and two (2) staff files, including criminal record clearances. 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. LPA verified staff training for staff file reviews.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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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: KELLY ACACIO'S CARE HOME
FACILITY NUMBER: 347001602
VISIT DATE: 05/17/2024
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The following forms and documents were requested to be submitted within 15 days:
LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, Administrator Certificate, Surety Bond, and LIC 610 Emergency Disaster Plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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