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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003784
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:14:20 PM

Document Has Been Signed on 02/22/2023 12:14 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WOLFE-RIVERA RESIDENTIAL MANOR, LLC #2FACILITY NUMBER:
347003784
ADMINISTRATOR:WOLFE, PATRIA/RIVERA, VIOLFACILITY TYPE:
735
ADDRESS:7927 TUNGSTEN WAYTELEPHONE:
(916) 629-9142
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY: 6CENSUS: 4DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Patria WolfeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 2/22/23 at 10:00am. LPA met with Patria Wolfe, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents participating in individual activities during this visit. License Fees are current. LPA observed adequate supply of 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 70 *F which is within the required range of 68-85*F. The hot water temperature was measured at 115.2*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Affidavit Regarding Client/Resident Cash Resources(LIC 400)
Control of Property, Application (LIC200), Liability Insurance, Personnel Report (LIC500)
Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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