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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701324
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:46:10 PM

Document Has Been Signed on 01/18/2024 03:46 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:KIMBALL HILL CARE HOME LLCFACILITY NUMBER:
502701324
ADMINISTRATOR:KAUR, TASWARDEEPFACILITY TYPE:
735
ADDRESS:3129 KIMBALL HILL DR.TELEPHONE:
(209) 535-4952
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 4CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rammy Kaur, LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived announced to conduct a prelicensing inspection. LPA Campbell met with Licensee Rammy Kaur and explained the purpose of the visit. The licensee stated that a house sitter and two children were currently living in the home until residents were received.

LPA Campbell toured the facility with the licensee and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees.

LPA Campbell observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. On the dining room wall, the facility has posted Personal Rights, the facility sketch, and emergency contacts. In the backyard, LPA Campbell observed a backyard surrounded by wooden fencing with an empty concrete patio and an outdoor shed.

Full and twin beds were observed in the shared bedroom. The licensee stated another twin bed would be brought in for the residents after the full bed was removed. Storage and organization areas for medicine, lock boxes, activity supplies, etc were identified but the items had not been put in place. No landline had been installed and the large See Something Say Something poster was not installed on the wall.

Deficiencies were observed during this visit. Licensee Kaur agreed to correct the observed deficiencies by February 5, 2024. LPA Renee Campbell will return at a later date to assess corrections. An exit interview was conducted and a copy of this report was left with Kaur.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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