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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002807
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:09:42 PM

Document Has Been Signed on 08/06/2024 01:09 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:IMAGINEFACILITY NUMBER:
525002807
ADMINISTRATOR/
DIRECTOR:		LEAK, TAMRAFACILITY TYPE:
735
ADDRESS:25347 LEE STTELEPHONE:
(530) 604-2602
CITY:LOS MOLINOSSTATE: CAZIP CODE:
96055
CAPACITY: 6CENSUS: 6DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Administrator- Tamra Leak TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 08/06/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility
unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator,
Tamra Leak and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in
care. LPA observed the facility to be clean, in good repair and odor-free. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms.
LPA observed all resident bedrooms to have all the required furnishings, windows with screens and
working lights. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or
shower chair, trash can with lids and 20-second hand-washing poster. LPA observed the facility to
have the required 2-day perishable and a 7-day non-perishable amount of food and sharps to be
locked. Hot water temperature was measured at 114 F. LPA observed the medications to be locked
and inaccessible to residents.

LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA
observed a completed first aid kit ready for emergency use. LPA observed a completed emergency
disaster plan with the required emergency disaster drills conducted within the last 12 months.
In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of six (6) residents' files and four (4) staff files which contains all of the
required documentation.
Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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