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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700081
Report Date: 03/21/2023
Date Signed: 03/21/2023 03:57:35 PM

Document Has Been Signed on 03/21/2023 03:57 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MICHELE'S FAMILY HOMEFACILITY NUMBER:
392700081
ADMINISTRATOR:ATKINS, MICHELEFACILITY TYPE:
735
ADDRESS:338 SPARROW LANETELEPHONE:
(209) 747-4639
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 2CENSUS: 2DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Michele Atkins, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on 03/21/2023 LPA met and toured the facility with Administrator, Michele Atkins. The administrator currently holds a certificate (#6031560735) that expires on 07/27/2024.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 2 total bedrooms of which 1 bedroom is occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction.. A comfortable temperature for clients is maintained at 70-degree Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients.. Due to client's GJ Tube for feeding, there is more than 7 days worth of non-perishable foods available.

Smoke detectors and carbon monoxide alarm were in operating condition during visit. Fire extinguisher was last serviced on May 03. 2022. First aid kit was observed to be complete. Fire drill was last conducted on 02/28/2023.

Staff records were reviewed, and all staff have criminal record clearance or a criminal record exemption and holds a current first aid certificate.
LPA reviewed 2 of 2 files for clients and reviewed 3 of 4 files for staff.

No deficiencies were cited during this inspection.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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