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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 04/22/2024
Date Signed: 04/22/2024 09:30:33 AM

Document Has Been Signed on 04/22/2024 09:30 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/
DIRECTOR:
KHAN, SHAKILFACILITY TYPE:
735
ADDRESS:12717 HAUSCHILDT ROADTELEPHONE:
(209) 200-3046
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 4DATE:
04/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:19 AM
MET WITH:Victoria GomezTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a health and safety case management visit. LPA met with House Manager (HM)Victoria Gomez, and explained the purpose of the visit.

Upon arrival, LPA Valerio observed 2 residents waiting for their ride to their Day Program. LPA Valerio spoke to residents while they waited. LPA learned the staff and residents returned from a week long trip. Resident expressed excitement over being able to go to Disneyland, Universal Studios, and on a road trip. LPA observed staff and resident interactions to be supportive, positive, and friendly.

LPA Valerio and HM Gomez toured the facility to ensure there were no immediate health or safety concerns. LPA Valerio inspected the facilities food supply. The food appeared fresh and in abundance. The facility met the minimum requirements of 2 days of perishable food items, 7 days of nonperishable food items, and an emergency supply of food. The common areas were observed to be clean, free from debris, and free from odors. LPA observed 4 resident rooms. All resident rooms were fully furnished, clean, and free from odors. Medications, sharps, and cleaning supplies were locked and inaccessible to residents in care. LPA observed the resident bathroom to be fully stocked and clean. The exterior plant was observed to be in good condition with areas to have outdoor activities and visits.

No health or safety concerns were observed during today's visit.

An exit interview was conducted with House Manager Gomez, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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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