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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004884
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:35:53 AM

Document Has Been Signed on 02/07/2023 09:35 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:KAREN'S CASTLEFACILITY NUMBER:
347004884
ADMINISTRATOR:DAVIS-HARO, KARENFACILITY TYPE:
735
ADDRESS:8701 SANGRIA COURTTELEPHONE:
(916) 686-0766
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 3CENSUS: 3DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Karen Davis-HaroTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual inspection. LPA met with facility staff, and explained the purpose of the visit.

LPA requested the following documentation: LIC 500, Surety Bond, LIC 308, Administrator Certificate, Emergency Disaster Plan

LPA toured the facility to ensure compliance of Title 22 regulations. Residents were observed to be leaving for day program and getting ready for their day. LPA observed resident bedrooms to have necessary furniture and furnishings. Bedrooms were observed to be clean, organized, and odorless. Bathrooms were observed to have soap, paper towels, hand sanitizer, and a lid trash can. Common areas were clean and organized. The facility had sharps, cleaning supplies, and medications locked and inaccessible to residents in care. The hot water temperature was measured at 110.0*F, which is within the regulatory range. Room temperature was measured at 72*F. A first aid kit was observed to have necessary items. There is a minimum of 7-day nonperishable and 2-day perishables foods.

Per California Code of Regulations, Title 22, no deficiencies were observed during today's visit. An exit interview was held with facility staff, and copy of the report was provided and left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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