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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 08/16/2022
Date Signed: 08/18/2022 09:53:04 AM

Document Has Been Signed on 08/18/2022 09:53 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
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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shakil KhanTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) R. Campbell conducted an unannounced required yearly visit with Administrator Shakil Khan. The administrator currently holds a certificate (#6008267735) that expires on 12/04/2023. The facility’s fire clearance was approved for 1 non-ambulatory and 3 ambulatory bedrooms.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 4 bedrooms are occupied by the clients and 0 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/28/2022 Emergency Disaster Plan was last posted on 07/20/2022. First aid kit was observed to be complete. Fire drill was last conducted on 07/29/2022

Staff records were reviewed, and all staff have criminal record clearance or a criminal record exemption and holds a current first aid certificate.

The following forms to be updated and submitted to CCL by 09/01/20222

-LIC 999 (3/99) - Facility Sketch

No deficiencies were cited during this inspection.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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