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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003869
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:25:03 PM

Document Has Been Signed on 08/13/2024 03:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TATE FAMILY CARE #2FACILITY NUMBER:
347003869
ADMINISTRATOR/
DIRECTOR:		TATE, CHERESEFACILITY TYPE:
735
ADDRESS:8517 AVERY CTTELEPHONE:
(916) 627-1992
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Cherese TateTIME VISIT/
INSPECTION COMPLETED:
03:38 PM
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On 08/012/2024 at 12:45 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with licensee/administrator Cherese Tate and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # is 7002940735 and will expire on 02/04/2026. The current census is 4 with 2 facility staff.

This facility is a single story building licensed to serve four (4) ambulatory developmentally disabled clients.
LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room garage and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed the facility had sufficient seven-day non-perishable food supplies and 2 days perishable food supplies. Hot water temperature was measured at 105.8 degrees Fahrenheit in client’s bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen and was last serviced on 05/09/2024. The last fire drill was conducted on 07/30/2024. LPA Lee observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 78 degrees Fahrenheit. LPA observed toxins located in the storage cabinet in the hallway and it was kept locked and inaccessible to clients. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA and administrator reviewed and compared 4 out of 4 medication administration record (MAR) along with Clients medications and they were complete. LPA Lee asked to inspect the facility’s first aid kit and it was complete.

Continued LIC 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TATE FAMILY CARE #2
FACILITY NUMBER: 347003869
VISIT DATE: 08/13/2024
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LPA requested client and staff files for review. LPA reviewed 4 out of 4 clients files and they were complete. LPA reviewed 2 staff files and they were also complete. LPA interviewed 1 facility staff and 4 clients during today’s visit. During today’s visit, LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by 08/19/2024 end of day 5:00 PM.

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Bond Insurance
(5) Administrator Certificate

As a result of this annual visit, the facility is in compliance with Title 22 Regulation, and no deficiencies were cited. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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