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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002088
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:36:24 PM


Document Has Been Signed on 02/28/2024 02:36 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Domnica Duncan, CaregiverTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 2/28/24 and met with the caregiver to conduct a Required-1 Year Inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (3) bedrooms and four (4) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to the resident. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the resident in care. Smoke and Carbon Monoxide detectors are hard wired and operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

LPA checked medication storage and found medications to be locked away and inaccessible to the resident. LPA reviewed one (1) resident file.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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