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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002402
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:12:57 PM

Document Has Been Signed on 04/27/2023 02:12 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:ED DAVID CARE HOMES INC. #3FACILITY NUMBER:
347002402
ADMINISTRATOR:MARINA DAVIDFACILITY TYPE:
735
ADDRESS:4028 DEXTER CIRCLETELEPHONE:
(916) 331-2634
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 6DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Grace Woodford, AdministratorTIME COMPLETED:
02:16 PM
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On April 27, 2023, (LPA) De Anna Williams-Lyons made an unannounced visit to conduct facilities required annual inspection. LPA Lyons met with administrator, Grace Woodford, and informed her the reason for the visit. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water temperature measures at 108 degrees F.
LPA reviewed 3 resident records. Resident files were found to be complete and current.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Administrator submitted the following documents to update the Regional Office files on Community Care Licensing

-LIC 500 facility personnel or staff schedule


-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
-copy of liability insurance
-updated facility sketch
The will be due May 27, 2023

Exit interview conducted and a copy of this report given to Madelyn
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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