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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 10/04/2023
Date Signed: 10/05/2023 12:20:36 PM


Document Has Been Signed on 10/05/2023 12:20 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/05/2023 11:48 AM

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

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On 10/05/23, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.
LPA reviewed

1. Maintenance logs

2. Medication log sheets

3. Updated AWOL procedures

4. Recent incident reports

5. Random resident medical assessments

6. Training records

7. Facility observation to ensure compliance and safety

Based on random records review of resident files services plans are updated and MAR'S are singed, the Medication room narcotics log is singed.

Exit interview conducted. Copy of report left at facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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