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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:10:38 PM


Document Has Been Signed on 02/23/2023 03:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Emerlinda SiebenthalTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 02/23/2023 at 1:18 PM. LPA Martinez met with Emerlinda Siebenthal and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for two.

LPA Martinez toured the facility with the Emerlinda Siebenthal on 02/23/2023 at 2:00 PM.

The facility has one main Covid-19 screening entry point, and has a supply of PPE. The facility also has an infection control plan. The facility is sanitary and clean. The facility common areas are clean and furnished. The facility water temperature measured at 105 degrees. The facility temperature measured at 76 degrees. The fire extinguishers are in good repair. The emergency exit gate is in good repair. The facility has an adequate food supply. The facility laundry room is in good repair. The facility has a locked closet for medications, and the first aid is in good repair. Resident rooms and bathrooms are in good repair and furnished.

There were no deficiencies cited at this annual visit. An exit interview was conducted, and a copy of this report was provided to the Licensee at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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