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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005652
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:01:49 PM

Document Has Been Signed on 01/29/2024 12:01 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:SOUTH AREA ADULT GROWTH EXPERIENCEFACILITY NUMBER:
347005652
ADMINISTRATOR:SHELLY PEFLEYFACILITY TYPE:
775
ADDRESS:211 LATHROP WAY SUITES A-DTELEPHONE:
(916) 561-0956
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 59CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ka ChangTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at South Area Adult Growth Experience for the purpose of conducting an unannounced required 1 year annual inspection. LPA met with Program Supervisor Ka Chang, and together conducted a tour of the facility. No clients were at the facility at the beginning of the tour.

This facility is an adult day program single story building with 4 suites. Licensed to serve six (59) ambulatory clients of which 35 may be non-ambulatory. LPA toured the physical plant including but not limited to client bathrooms and activity areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed the facility kitchen area. Hot water temperature was measured at 119 degrees Fahrenheit in bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 9/11/2023. LPA observed toxins and sharp knives kept locked and inaccessible to clients. First aid kit was checked and is complete.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, 3 client and 3 staff files, all files are in order in accordance to Title 22 Regulations.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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