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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700342
Report Date: 11/08/2023
Date Signed: 11/09/2023 12:21:29 PM


Document Has Been Signed on 11/09/2023 12:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PATTERSON CAREHOME LLCFACILITY NUMBER:
502700342
ADMINISTRATOR:PAMITTAN, JEANNAFACILITY TYPE:
740
ADDRESS:142 PALOMINO WAYTELEPHONE:
(650) 477-8065
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY:6CENSUS: 5DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Tahiri PalominoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with Administrator Tahiri Palomino and explained the reason for the visit. Census: 5

LPA Lund & Administrator Tahiri Palomino toured/inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven-day nonperishable and two-day perishable food supplies.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 2 resident and 2 staff files, including criminal record clearances. Fire drill was completed on 10/13/2022. Fire extinguishers (7/26/2023) & carbon monoxide detector are incompliance. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and complete.

No deficiencies were cited during the visit. Exit interview conducted and copy of report given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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