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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 09/14/2023
Date Signed: 09/14/2023 11:41:25 AM

Document Has Been Signed on 09/14/2023 11:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hanif KhanTIME COMPLETED:
12:00 PM
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On 9/14/23 at approximately 8:30am Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager Liza King arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Hanif Khan and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 4 bedrooms and 2 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 3 ambulatory residents and 1 non ambulatory resident.

Facility Observation: Upon entry the residents were happy to see visitors and departing for day program. LPA observed a “House Store” with items for purchase including but not limited to a song, trip to the park, arts and crafts kit. Coins used to purchase store merchandise were earn by completing daily tasks including but not limited to showering, relaxation and dialing the phone. Each resident had a laminated sheet with their name on it and a place to Velcro coins. Residents’ rooms had personal items including but not limited to posters, family photos, trains, sports memorabilia. A large wall mounted whiteboard in the family room held the calendar for the month’s appointments. A flyer on the wall listed evening activities including but not limited to karaoke, ice cream social, games night, movie night.

During this inspection 4 of 4 resident files and 4 of 9 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHAKIL'S CARE HOME
FACILITY NUMBER: 347004550
VISIT DATE: 09/14/2023
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Water temperature in common bathroom reads 116*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was serviced 5/12/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills.

A review of resident files revealed a mistake on the 602 of 1 resident. Technical Assistance (TA) was provided to have the document corrected.

LPA requested an updated copy of LIC 308, 610D, Surety Bond and LIC 500. The LIC500 and 610D were received the 308 and Surety Bond to be emailed to Jennifer.Fain@dss.ca.gov

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Safaraz Khan.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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