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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004350
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:17:39 PM

Document Has Been Signed on 05/02/2024 03:17 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/
DIRECTOR:
EDMON ORIANFACILITY TYPE:
735
ADDRESS:3909 HENDERSON WAYTELEPHONE:
(916) 550-1473
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Josephine Morales and Edmon OrianTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 5/2/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual inspection utilizing the full care tool. LPA met with direct support professional, who contacted Administrator, who arrived to the facility shortly afterwards.

During today's visit, LPA observed four clients in care. Clients were observed to be resting. LPA observed three direct support professionals to be working during time of visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of clients in care. Areas toured included but not limited to: clients bedrooms, bathroom, kitchen, sun room/activity room, dining room, backyard and the common areas. LPA observed the facility to have ample supply of perishable and nonperishable food present in the facility. LPA observed facility to have personal protective equipment available. Facility has various activities available for clients in the activity room. In areas toured, no immediate health, safety and personal rights violation was observed.

Additionally, LPA and Administrator discussed CCR 85068.4 Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients... The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. LPA provided Administrator a copy of 80024 Waivers and Exceptions and 85068.4 Acceptance and Retention Limitations.

File review was conducted four clients and three staff. LPA found facility to have the required documents on file. Annual Inspection tool completed and found facility to be in compliance. No deficiencies cited.

Exit interview and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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