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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347005733
Report Date:
08/30/2024
Date Signed:
08/30/2024 01:41:39 PM
Document Has Been Signed on
08/30/2024 01:41 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SIGNATURE LIVING RCFE
FACILITY NUMBER:
347005733
ADMINISTRATOR:
FLORES, HAZEL
FACILITY TYPE:
740
ADDRESS:
7315 POCKET ROAD
TELEPHONE:
(916) 346-4128
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95831
CAPACITY:
6
CENSUS:
6
DATE:
08/30/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
01:36 PM
MET WITH:
Diana Bonuccelli
TIME COMPLETED:
02:15 PM
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On 8/30/21 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure previous deficiencies have been corrected. LPA met with staff Diana who showed LPA a new syringe disposal container that was larger and could accommodate disposed of syringes and not be too full and pose a danger to staff members and other professionals serving residents in care.
POC clearance letter generated and a copy of this report was left at the home.
SUPERVISOR'S NAME:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
08/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/30/2024
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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