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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003723
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:55:29 AM

Document Has Been Signed on 02/14/2024 11:55 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:CHARIBEL JOSE CARE HOME, INC.FACILITY NUMBER:
347003723
ADMINISTRATOR:BALBUENA, EVELIOFACILITY TYPE:
735
ADDRESS:5831 TREE HILL CTTELEPHONE:
(916) 332-5277
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 3DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator- Charibel Jose TIME COMPLETED:
12:00 PM
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On 02/14/24 Licensing Program analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required- 1 year annual inspection utilizing the care tool. LPA met with Administrator, Charibel Jose and explained the purpose of visit.

LPA and Administrator conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, two (2) private residents bedrooms, one (1) shared resident room, two (2) bathrooms, garage, common areas and backyard. LPA observed sufficient furniture and lighting throughout the facility. The facility has the required postings in common areas. During time of visit one (1) resident was present in the facility doing different activities.

LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed centrally stored medications, knives and toxins to be locked and inaccessible to residents in care. Hot water temperature was measured at 108 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. Fire extinguishers was last inspected on 08/25/23. Smoke detectors and carbon monoxide detectors are working and present throughout the facility.

LPA conducted a file review of three (3) resident files and two (2) staff files. LPA observed all resident files and staff files to be in compliance.

LPA completed the full care tool and no deficiencies was observed.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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