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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:39:25 PM

Document Has Been Signed on 04/13/2022 03:39 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHAKIL'S CARE HOMEFACILITY NUMBER:
347004550
ADMINISTRATOR:KHAN, SHAKILFACILITY TYPE:
735
ADDRESS:12717 HAUSCHILDT ROADTELEPHONE:
(209) 200-3046
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Natalie Willman, House ManagerTIME COMPLETED:
03:55 PM
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On 04/13/2022, Licensing Program Analysts (LPAs)T. White and R. Campbell, conducted an unannounced case management visit regarding an incident report which occurred on 03/14/2022. LPAs met with House Manager, Natalie Willman and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 03/15/2022. Based on incident report, Client #1 (C1) is prescribed Melatonin medication during dinner and bedtime. Based on refill prescription, it stated C1 was prescribed Melatonin for bedtime only. Staff #1 (S1) called on 03/14/2022 and explained to the doctor that he had sent over an old prescription. Approximately an hour later the pharmacy resent the same prescription again. S1 called the pharmacy again and there was no answer. At that time, it is nearing C1's dinner medication and C1 missed melatonin dose. On 03/15/2022, S1 received confirmation after calling the Doctor's office and speaking with front desk staff. The Doctor sent corrected prescription and apologized for the inconvenience.

No deficiencies cited during visit.

Exit interview conducted with House Manager and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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