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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000839
Report Date: 01/16/2024
Date Signed: 01/16/2024 03:00:56 PM


Document Has Been Signed on 01/16/2024 03:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/16/2024 02:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with administrator and explained purpose of visit. Administrator certificate expires 9/21/2024.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, client bedrooms; client bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 112.7 degrees Fahrenheit which is within the required range of 105 to 120 degrees.

Fire extinguishers last inspected on 2/8/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducted fire/disaster drills with clients on 12/30/2023.

LPA reviewed four client files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit.

Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) were left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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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