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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701276
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:40:34 AM


Document Has Been Signed on 04/13/2023 10:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GABRIELLE'S CARING HANDFACILITY NUMBER:
502701276
ADMINISTRATOR:ANTONIA, TABITHAFACILITY TYPE:
740
ADDRESS:2921 ZARAND DRTELEPHONE:
(408) 823-0358
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ma Tabitha AntonioTIME COMPLETED:
11:00 AM
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On 04/13/2023 at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility announced to conduct a Pre-Licensing Visit. LPA Pascua met with Facility Designated Administrator, Tabitha Antonio and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit due to a change of location. This facility has a Dementia Program on file and a hospice waiver for 6.
Current census was 0. Facility Designated Administrator has a current and active certificate #6055145740 and expires on 01/27/2024.
The fire extinguisher, located in the kitchen area, was serviced by Jorgenson Company on 02/06/2023. Carbon Monoxide and fire alarms were present and in good repair.
Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance.
A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional.
Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition.
A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 7-day nonperishable food supply at this time.
Garage area was toured. Laundry detergent and cleaning supplies were locked and made inaccesible at this time.
This facility will be using a medication cart which was located in the living room. LPA observed the medication cart to be locked and made inaccessible at this time.
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GABRIELLE'S CARING HAND
FACILITY NUMBER: 502701276
VISIT DATE: 04/13/2023
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Exterior grounds of this facility was toured.
Perimeter fence and gates were observed to be functional and in good repair at this time.
This facility has been observed to be in compliance at this time.

There were no deficiencies observed during the course of this Pre-licensing visit.

Component III will be waived at this time.

Exit Interview was conducted and a copy of this report was provided to the Facility Designated Administrator at the end of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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