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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002088
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:21:17 PM


Document Has Been Signed on 03/29/2023 02:21 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:DELL VILLA CARE HOMEFACILITY NUMBER:
347002088
ADMINISTRATOR:DUNCAN, GREGORYFACILITY TYPE:
740
ADDRESS:8900 FAIR OAKS BLVD.TELEPHONE:
(916) 944-8148
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 1DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dominica DuncanTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 3/29/23 to conduct a Annual inspection. LPA met with staff Dominica and explained the purpose of the visit. LPA PPE was worn: surgical Mask. Gregory arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

There is one resident in care.
Files were reviewed for one resident and one caregiver.
Files were complete for required documentation.
Staff training certificates will be updated and on file.
If a non-caregiver adult moves into the house, they will be fingerprint cleared.


Fire extinguishers were off site to be recharged. Fees have been paid and are in processing.

As a result of this inspection, no deficiencies were sited

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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