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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004963
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:41:54 PM

Document Has Been Signed on 11/08/2024 02:41 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MILES MANORFACILITY NUMBER:
347004963
ADMINISTRATOR/
DIRECTOR:
MILES, RACHELFACILITY TYPE:
740
ADDRESS:4301 WATKINS DRIVETELEPHONE:
(916) 967-9049
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kimberly RosaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived unannounced to conduct an annual inspection. LPAs met with Kimberly Rosa during today's inspection.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed ten (10) resident rooms and two (2) common area bathrooms. LPAs observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 113.1 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPAs checked medication storage and found medications to be locked away and inaccessible to the residents. LPAs reviewed six (6) resident files, three (3) staff files and two (2) resident medications. Facility has a current copy of certificate of liability insurance and LPAs requested a copy.

As a result of this visit, no deficiencies were cited.

Exit interview was conducted with Administrator. A copy of this report provided.
Anthony PerezTELEPHONE: (323) 485-4915
Cassandra MikkelsonTELEPHONE: 916-709-6830
DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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