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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700526
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:04:01 PM

Document Has Been Signed on 03/20/2024 03:04 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:MIH-3 CARE HOMEFACILITY NUMBER:
502700526
ADMINISTRATOR:RYAN, MICHAELFACILITY TYPE:
735
ADDRESS:5413 FARMERS LNTELEPHONE:
(209) 244-3898
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 4CENSUS: 4DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Cami Azevedo TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA Lund met with Administrator Cami Azevedo and explained the purpose of the visit. Census: 4

LPA Lund & Administrator Cami Azevedo inspected/toured the physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Hot water temperature was measured at 116 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. Fire drill was conducted on 2/16/2024. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed two residents and three staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during this visit. Exit interview held and a report given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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