502700864-9-29-2023-27-AS-CYAG-CW5MJE-20230929093901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700864
Report Date: 09/27/2023
Date Signed: 09/29/2023 09:39:05 AM

Document Has Been Signed on 09/29/2023 09:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SHELTERING ARMS LLC		FACILITY NUMBER:	502700864
ADMINISTRATOR:	DHILLO, JATINDER		FACILITY TYPE:	735
ADDRESS:	1112 TWILIGHT DRIVE		TELEPHONE:	(209) 535-7588
CITY:	CERES	STATE: CA	ZIP CODE:	95307
CAPACITY: 4		CENSUS: 4	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jatinder Dhillon		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 09/27/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregivers who were requested by this LPA to go ahead and contact the facility designated Administrator Jatinder Dhillon and inform him that CCL was present at this time. The facility designated Administrator Jatinder Dhillon arrived shortly thereafter to this facility while this LPA was conducting this annual visit. Brief interview was conducted with the facility designated Administrator at this time. Current census was 4 residents. It was learned that (2) residents were out of the home at their respectable day programs at this time. This facility was vendorized to accept and retain Level 4I residents through Valley Mountain Regional Center. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Jatinder Dhillon. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 04/05/2024. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe an additional food storage unit which was present and functional at this time in the designated staff room. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the facility office area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHELTERING ARMS LLC	FACILITY NUMBER: 502700864
	VISIT DATE: 09/27/2023

NARRATIVE

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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Garage area was toured. This area housed additional furniture and supplies for the facility residents.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located in facility kitchen area, was observed to have been annually purchased on 07/17/2023 by the local hardware store and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (4) facility resident records was conducted.
A review of (5) facility staff records was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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