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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003931
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:09:46 AM

Document Has Been Signed on 05/04/2023 10:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BILBY HOME INC.FACILITY NUMBER:
347003931
ADMINISTRATOR:ANNE CARILLOFACILITY TYPE:
735
ADDRESS:5411 MARIOLYN WAYTELEPHONE:
(916) 670-6015
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anne CarilloTIME COMPLETED:
10:30 AM
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On 5/4/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a Case Management visit. Upon LPAs arrival, facility staff Ella Carillo was present and contacted Administrator Anne Carillo who arrived a bit later. LPA met with Anne Carillo and explained the purpose of the visit. There are currently 6 clients who reside at this facility.

The purpose of today's visit is in response to substantial inadequacies identified by Alta California Regional Center during an annual Title 17 Monitoring Review on 3/6/23. It was learned that the facility was placed on sanction on 3/13/23 due to the following deficiencies:
- Failure to provide consumer services as specified in the consumer’s IPP.
- Conditions posting a threat to the health and safety of any consumer, that are not considered an immediate danger.

LPA conducted a review staff files to ensure all staff have all appropriate training per Title 22.

No deficiencies were observed during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes.



Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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