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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003327
Report Date: 09/22/2023
Date Signed: 09/22/2023 12:34:52 PM

Document Has Been Signed on 09/22/2023 12:34 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:AILEEN CANTOR-FERMO RESIDENTIAL CARE HOMEFACILITY NUMBER:
347003327
ADMINISTRATOR:FERMO-CANTOR, AILEENFACILITY TYPE:
735
ADDRESS:7016 22ND STREETTELEPHONE:
(916) 992-1904
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 6DATE:
09/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Aileen Fermo-CantorTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility to conduct a case management visit regarding an incident report the Department received. LPAs met with Administrator, Aileen Fermo-Cantor, who stated the incident occurred at her elderly facility, not her adult residential.

LPAs and Administrator discuss the importance of providing the correct name of facility on incident reports as LPA Yang observed the name of the facility listed on the incident report to state: Aileen Cantor-Fermo Residential Home.

Administrator informed LPA she will meet LPAs at her elderly care facility.

LPAs vacated the premises.

Exit interview, a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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