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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700603
Report Date: 07/27/2023
Date Signed: 07/27/2023 10:02:37 PM

Document Has Been Signed on 07/27/2023 10:02 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:AUSTIN ROAD HOMEFACILITY NUMBER:
392700603
ADMINISTRATOR:WARREN, KATHYFACILITY TYPE:
735
ADDRESS:16590 S AUSTIN RDTELEPHONE:
(209) 823-6061
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 5DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melinda WombleTIME COMPLETED:
01:00 PM
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Unannounced annual licensing visit made out to this facility on 07/27/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Amy Glass, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Melinda Womble, to inform her that CCL was present at this time. The facility designated Administrator, Melinda Womble, arrived shortly thereafter to this facility. A brief interview was conducted with the facility designated Administrator at this time.
This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 4F residents at this time.
Current census was 5 residents. It was learned that (4) of the residents were not present at this time since they attended their own day programs. There was only (1) resident present at the time of this visit.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Drawers containing knives and other cutlery were observed to be locked and made inaccessible to the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Additional nonperishable food items were observed to be stored in the garage area along with additional refrigerator and freezer units.
Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time.
A tour of the resident restrooms was conducted. Shower areas, toilets, and wash basins were reviewed and observed to be functional and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Medication for resident use, located in entry way cabinet, was reviewed. Policies and procedures for
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AUSTIN ROAD HOME
FACILITY NUMBER: 392700603
VISIT DATE: 07/27/2023
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dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time.
Fire extinguishers (3) were observed to be placed in the kitchen area, dining area, and laundry area and were annually inspected on 01/12/2023 from the local fire extinguisher company, Jorgensen Co, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located in facility hallway, was observed to be locked and made inaccessible to the residents at this time. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored in cabinets where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.
A review of (4) facility personnel files was conducted.
A review of (4) facility resident files was conducted.

The following forms were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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