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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700864
Report Date: 09/16/2024
Date Signed: 09/16/2024 01:53:11 PM

Document Has Been Signed on 09/16/2024 01:53 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:SHELTERING ARMS LLCFACILITY NUMBER:
502700864
ADMINISTRATOR/
DIRECTOR:		DHILLO, JATINDERFACILITY TYPE:
735
ADDRESS:1112 TWILIGHT DRIVETELEPHONE:
(209) 535-7588
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 4CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jatinder SinghTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPAs) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 09/16/2024.  LPA Campbell met with Jatinder Singh, Administrator/Licensee and explained the purpose of the visit. Licensee and Administrator Davinder Dhillon also was present during today’s visit as well.

LPA Renee Campbell toured the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and the backyard of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (4) ambulatory residents. LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Food was present in the pantry and refrigerator in the kitchen. Food was also stored in a freezer and on shelves in the garage. The kitchen water temperature measured at 106.5 degrees and the resident bathroom water temperature measured at 110.7 degrees. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. The fire extinguisher was purchased on 07/17/2024 and shows as charged. The Record of Fire Drills was reviewed and confirmed monthly fire drills were conducted for the past 8 months.

The facility thermostat was observed at 72 degrees Fahrenheit. The temperature for the refrigerator in the kitchen is observed at -6 Fahrenheit for the freezer and 42 degrees Fahrenheit for the refrigerator. LPA Campbell found medication to be locked away and inaccessible to clients in the facility office. The First aid kit was complete and contained; tweezers, scissors and bandages. A thermometer for clients was also observed stored in a separate cabinet.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SHELTERING ARMS LLC
FACILITY NUMBER: 502700864
VISIT DATE: 09/16/2024
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LPA Campbell requested 4 of 4 client files and 4 of 12 staff files for review. The client files reviewed were found to be complete. Of the 4 staff files reviewed, one file had an expired CPR /First Aid certificate. Once the administrator was notified, staff were able to verify they had completed their renewal and provided the printed certificate for their file during the visit and no citation was issued. Toxins were observed in a locked closet inaccessible to clients in care. LPA Campbell reviewed the roster provided and verified that all staff are fingerprint cleared.
The following documents will be emailed to LPA Campbell (Renee.Campbell@dss.ca.gov) by 09/23/2024 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(4) LIC 610 Emergency Disaster Plan

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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