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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 03/02/2023
Date Signed: 11/28/2023 09:55:50 AM


Document Has Been Signed on 11/28/2023 09:55 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:FRUITFUL HUMBLE ABODEFACILITY NUMBER:
392700899
ADMINISTRATOR:MABUNGA, JOYCE MAEFACILITY TYPE:
740
ADDRESS:1849 COIT STREETTELEPHONE:
(415) 619-9510
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 5DATE:
03/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joyce MabungaTIME COMPLETED:
03:00 PM
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Unannounced plan of correction visit made out to this facility on 03/02/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Joyce Mabunga. Brief interview was conducted with the facility designated Administrator.
Current census was 5 residents.
The purpose of this visit was to review the plan of correction that was enacted for the annual visit that was conducted on 01/25/2023 and to make sure that the corrections were properly performed and items brought into compliance:
  • All window screens shall be clean and maintained in good repair.

  • The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.


Plan of correction was completed and items cited above were brought back into compliance.

Plan of correction clearance letter was printed and a copy was left with the facility designated Administrator at this time.

There were no deficiencies observed or further cited during today's plan of correction visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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