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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700755
Report Date: 05/28/2021
Date Signed: 05/28/2021 01:37:44 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
FACILITY NAME:GABRIELLE'S CARING HANDFACILITY NUMBER:
502700755
ADMINISTRATOR:ANTONIO, MA TABITHAFACILITY TYPE:
740
ADDRESS:3109 WATERBURY CTTELEPHONE:
(408) 823-0358
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 4DATE:
05/28/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ma Tabitha AntonioTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA Albert Johnson) conducted a Post-Licensing visit on today's date. LPA was met by Administrator. LPA conducted a tour of the interior and exterior areas of the facility. There are four (4) residents in the facility.

Client bedrooms, bathrooms, hallway, kitchen, family room and dining area was observed. Backyard was toured and observed clean and clutter free. The temperature in the home was comfortable. Medication, knives and toxins were all secured in cupboards and cabinets and inaccessible to clients.

The facility had the required carbon monoxide detectors throughout the home. Smoke detectors are operable. Fire extinguishers have been serviced. First aide kit was observed and had the required scissors, thermometer and tweezers.

LPA reviewed three (3) Staff records and three (4) client records. All files were complete. Staff are fingerprint cleared and first aid certified.

LPA observed the medication and the MARS sheets. LPA and the Administrator made sure the medications were documented accurately on the MARS. Medications appear to be documented appropriately.

Please see annual report for 5/28/2021 exit interview conducted. A copy of this report was left with the Administrator
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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