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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005570
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:42:59 PM


Document Has Been Signed on 06/29/2023 12:42 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:CLARA CARE HOMEFACILITY NUMBER:
347005570
ADMINISTRATOR:KIM, JAE YOELFACILITY TYPE:
740
ADDRESS:4665 FREEWAY CIRCLETELEPHONE:
(916) 900-4781
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Okki Kim, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/29/23 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPA observed bedrooms 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 115.6 degrees F.

LPA 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. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are hardwired and operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three resident files and also reviewed two staff files. Facility will email a current copy of certificate of liability insurance to LPA. Administrator has a current administrator certificate #6032658740 with an expiration date of 10/1/2024.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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