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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003931
Report Date: 01/02/2025
Date Signed: 01/02/2025 10:51:11 AM

Document Has Been Signed on 01/02/2025 10:51 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BILBY HOME INC.FACILITY NUMBER:
347003931
ADMINISTRATOR/
DIRECTOR:
ANNE CARILLOFACILITY TYPE:
735
ADDRESS:5411 MARIOLYN WAYTELEPHONE:
(916) 670-6015
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Ella Carillo, Anne Carillo TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with Designated Staff Ella Carillo, and explained the purpose of the visit. LPA was later met by Anne Carillo.

LPA Valerio toured the physical plant to ensure compliance with Title 22 regulations. LPA Valerio observed resident bedrooms. Resident bedrooms were observed to be clean, organized, free from odors, and personalized to each individual. Resident bathrooms were sanitary and fully stocked with hygiene supplies. Hot water faucets delivered water within regulatory range. The temperature inside the facility was noted to be at a comfortable temperature. Common areas were fully furnished without any obstructions to emergency exits. Fire extinguishers, carbon monoxide detectors, and heating/air conditioning systems were in working condition during the visit. The kitchen was observed to be well organized. The facility met the minimum requirement of 2 days of perishables and 7 days of non-perishable food items. Medications, sharps, and toxins were locked and inaccessible to residents in care. The backyard had areas for outdoor visitation, gates were in good repair, and emergency exits were clear from obstructions. No health or safety concerns were observed.

LPA reviewed three (3 resident files and three (3) staff files. Files were observed to be complete with required documentation.

LPA requested the following annual documentation be sent to the Regional Office by 01/23/2025: LIC 500, LIC 308, and LIC 610 - Emergency Disaster Plan, copy of surety bond

Per California Code of Regulations (CCR) - Title 22, Division 6, no deficiencies are being cited today. An exit interview was held with Administrator Anne Carillo, and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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