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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004083
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:55:59 PM


Document Has Been Signed on 01/18/2024 03:55 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:A & C CARE HOMEFACILITY NUMBER:
347004083
ADMINISTRATOR:SUAYBAGUIO, CECILIAFACILITY TYPE:
740
ADDRESS:2949 GARFIELD AVETELEPHONE:
(916) 488-8114
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cecilia SuaybaguioTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday January 18, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (6) and staff files (3). All resident files contained the required paperwork. All staff files contained the required paperwork and training. First aid kit was fully stocked. Facility had a full supply of PPE including face shields, surgical masks, N95s, gowns, and covid tests. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed.

LPA Parks and Administrator Cecilia toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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