<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004884
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:10:01 PM

Document Has Been Signed on 01/30/2024 04:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen Davis-HiroTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/30/24 at 1:45pm Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit. LPA met with the facility administrator, Karen Davis-HIro, and explained the purpose of today’s visit. The facility is currently licensed to serve 3 developmentally and intellectually disabled adults. Present during this visit, there were three (3) clients in care with one (1) staff on duty.

At 2pm, LPA inspected the facility’s physical plant including but not limited to the kitchen, dining room, client bedrooms, client bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises. Outside of the facility was observed to be clean and clear of obstructions. Additionally, LPA observed outdoor furniture for clients’ use and covered area for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed three (3) client bedrooms, two (2) bathrooms for client use. Staff office is detached from the house. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. All 3 client rooms inspected are privately occupied. Bathrooms were operational and adequately supplied.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to clients in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 70 degrees F. Water temperature in one of the bathrooms located inside bedroom #1 was measured at 110 degrees F. Smoke detectors and carbon monoxide were tested and found to be operable during this visit. Each client bedroom has smoke detector.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: KAREN'S CASTLE
FACILITY NUMBER: 347004884
VISIT DATE: 01/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
{Con't from LIC809}

Medication storage area was observed to be locked and inaccessible to clients in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. All mandated inspection control posters were posted. Facility has appropriate internet access available for client use. LPA observed sufficient equipment and supplies to meet activity program needs of clients in care.

During this inspection, LPA conducted an audit of facility files, three (3) client files, and three (3) staff files for regulatory compliance. All staff noted on LIC 500 have criminal background clearances and are associated to this facility. All client files reviewed contained all required contents including admission agreements, medical assessments, and individual program plan (IPP). All staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts monthly fire drills. LPA requested an updated copy of LIC 308, LIC 500, surety bond and liability insurance.

Per California Code of Regulations (Title 22, Division 6, Chapter 8), no deficiencies has been observed.

An exit interview was held with Karen Davis-Hiro, administrator, and a copy of this report and appeal rights were provided to the facility

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4