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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003327
Report Date: 11/27/2024
Date Signed: 11/27/2024 11:11:37 AM

Document Has Been Signed on 11/27/2024 11:11 AM - 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/
DIRECTOR:
FERMO-CANTOR, AILEENFACILITY TYPE:
735
ADDRESS:7016 22ND STREETTELEPHONE:
(916) 992-1904
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 6DATE:
11/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Aileen Fermo-CantorTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Administrator and explained the purpose of the visit. At the time of LPA's visit, four clients had left to adult day program with two clients remaining at the facility. LPA observed one direct support professional to be working with Administrator.

During today's visit, Administrator was provided a copy of facility pin code for annual licensing fees. Additionally, LPA and Administrator discussed if facility wish to change ownership from sole proprietorship to a limited liability company (LLC), Licensee is to submit a new application to Centralized Application Bureau located at 744 P Street Sacramento, CA 95814 with a new application fee of $908.

LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of clients in care. LPA inspected three shared clients rooms, two bathrooms, kitchen, laundry room, office and the common areas. In areas toured, no immediate health and safety concerns were observed.

LPA observed Administrator Certificate to be updated, expiration date of 10/10/2023 - 10/9/2025. LPA observed fire extinguishers recently serviced on 11/15/2024. LPA observed facility having the required posters posted in the common areas. LPA observed sharps, toxins and medications to be locked and inaccessible to clients in care.

File review was conducted for six clients and two personnel. LPA observed facility to have the required documents on file and documents up to date.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
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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