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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004560
Report Date: 05/27/2022
Date Signed: 05/27/2022 12:05:07 PM


Document Has Been Signed on 05/27/2022 12:05 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:ST. LUKE'S RESIDENTIAL FACILITYFACILITY NUMBER:
347004560
ADMINISTRATOR:COLLADO, JOHNNYFACILITY TYPE:
740
ADDRESS:4127 RIO LINDA BLVD.TELEPHONE:
(916) 568-9696
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 2DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Johnny ColladoTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual inspection on 05/27/2022. LPA met with Johnny Collado and explained the purpose of the visit. Johnny Collado is the Administrator and holds certificate #6010229740 that expires on 02/22/2024. LPA learned that a new certificate was not received. LPA was able to verify a current certificate status through CDSS.ca.gov Admin Cert portal.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and a hospice waiver for 1. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (107.4) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 03/28/2022. Thermostat observed at (72) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.
The following forms need updating and submitted to CCLD by 06/05/2022:
Liability Insurance Certificate, Administrator Certificate

No citations were issued during today's visit. Exit interview held with Johnny Collado and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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