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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001971
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:45:03 PM

Document Has Been Signed on 02/02/2023 03:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:RICK AND NICOLE FORTES CARE HOMEFACILITY NUMBER:
347001971
ADMINISTRATOR:FORTES, NICOLEFACILITY TYPE:
735
ADDRESS:5545 VILLAGE WOOD DRIVETELEPHONE:
(916) 395-3225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 5DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Nicole FortesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady and arrived unannounced to conduct a Required Annual Inspection on 02/02/2023 at 1:40 pm. LPA was allowed entry into the building LPA met with Nicole Fortes, administrator regarding todays visit. 3 residents are present and 2 residents are day program.

Administrator certificate for Nicole E Fortes Number 6015166735

LPA toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 114.6*F which is within the required range of 105-120*F.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke detectors and pull alarm system. Facility has central heating and air.

At 1:50 pm two resident files and two staff files were reviewed during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report emailed to Administrator due to printer malfunction.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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