455002996-7-11-2023-59-AS-RKNT-CTMP6E-20230711110212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455002996
Report Date: 07/11/2023
Date Signed: 07/11/2023 11:02:53 AM

Document Has Been Signed on 07/11/2023 11:02 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ANDERSON CREEK SRF		FACILITY NUMBER:	455002996
ADMINISTRATOR:	EZEANI, IFEANYI		FACILITY TYPE:	772
ADDRESS:	1901 BARNEY ROAD		TELEPHONE:	(916) 870-9676
CITY:	ANDERSON	STATE: CA	ZIP CODE:	96007
CAPACITY: 14		CENSUS: 0	DATE:	07/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Derrick Cobb - administrator		TIME COMPLETED:	11:20 AM

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07/11/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with administrator Derrick Cobb (#6065378735 exp. 01/18/2025) Safaratu Okolo Director of Programs, Michelle Frase Chief of Staff, Chia Lee LVN and explained the purpose of the visit.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for fourteen (14) ambulatory clients. The facility has seven (7) bedrooms and three (3) bathrooms which are set up with paper towels and soap for hand washing. LPA observed couches and chairs in the common room for clients to sit on and four tables and fourteen chairs in the dining room.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and working.

The facility has two (2) fully charged fire extinguishers which were inspected by the fire marshal in January 2023. LPA observed smoke alarms and carbon monoxide detectors fully functioning.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANDERSON CREEK SRF	FACILITY NUMBER: 455002996
	VISIT DATE: 07/11/2023

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Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility has a linen storage which contains towels and face cloths and extra sheets. Bathrooms were observed to be in good repair.

Storage and lighting are adequate in the home. Medications are to be stored in a locked room in a locked cabinet. Cleaning supplies and toxins are locked up in a cabinet in the hallway. Also locked in the kitchen are knives. Washer and dryer observed in place and ready for use.

There is a locking office space where client and staff files will be stored.

The yard has several large shade trees with chairs for the clients to use. There will be a designated smoking area in the recreation area.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

Exit Interview and copy of report was provided to the licensee.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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