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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005733
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:04:37 PM


Document Has Been Signed on 09/23/2022 03:04 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:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:ENERO,EDGARFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Heaven ZeraiTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 9/23/22 at 2:00pm. Administrator Certificate expires 4/24/23.

LPA met with Heaven Zerai, Caregiver and discussed the purpose of the visit. The facility is licensed for a capacity of 6 residents of which 1 maybe bedridden. Facility has a hospice waiver for 2 to receive hospice care services. There is 1 resident receiving hospice services at this time.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents who were engaged in activities during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 113.1*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Administrator Certificate-Updated
Personnel Report (LIC500)

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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