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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005202
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:09:11 PM


Document Has Been Signed on 02/15/2024 04:09 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:ST. CHRISTOPHER MANORFACILITY NUMBER:
347005202
ADMINISTRATOR:BENITEZ, NORMAFACILITY TYPE:
740
ADDRESS:8564 BRENTWICK WAYTELEPHONE:
(916) 509-9819
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:4CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Norma BenitezTIME COMPLETED:
04:30 PM
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On 2/15/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Required - 1 Year inspection visit. LPA met with Administrator Norma Benitez and explained the purpose of the visit.

Administrator holds current certification #6031100740 and expires on 11/30/2024. The facility is licensed for a capacity of 4 There is one resident who is using oxygen at this time.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 113.4*F which was within the required range of 105-120*F. The temperature inside the facility measured at 76*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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: ST. CHRISTOPHER MANOR
FACILITY NUMBER: 347005202
VISIT DATE: 02/15/2024
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LPA requested resident and staff files for review. LPA reviewed (1) staff files and (4) resident files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following forms and documents were requested to be submitted within 15 days:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan and Proof of Current Liability Insurance.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. Exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2