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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004350
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:47:41 PM

Document Has Been Signed on 06/29/2023 02:47 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:HENDERSON HOUSEFACILITY NUMBER:
347004350
ADMINISTRATOR:EDMON ORIANFACILITY TYPE:
735
ADDRESS:3909 HENDERSON WAYTELEPHONE:
(916) 550-1473
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 4DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Edmon OrianTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full CARE tool domain. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived shortly to the facility. Today's census is 4 clients in the care.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, recreational room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA observed four clients in care, three were in the common areas watching a movie and one was napping. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishables foods. LPA observed sharps and toxins to be locked and secured. LPA conducted a file review for one (1) client and two (2) staff files. All were found to be complete.

At this time, LPA requested a copy of LIC 500 to CCLD by July 7, 2023.

LPA and Administrator completed the care tool and found the facility to be compliance at this time. No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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