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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 04/26/2023
Date Signed: 04/28/2023 10:17:43 AM


Document Has Been Signed on 04/28/2023 10:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/28/2023 10:16 AM

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

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Licensing Program Analysts (LPA's ) Ruth Wallace and Kim Viarella conducted unannounced Required 1 Year Annual Inspection. LPA's met with Administrator and explained the purpose of the visit.

LPA's and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA's observed sufficient furniture and lighting throughout the facility. LPA's observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 110.5 in resident room 201 which is within the required range of 105 to 120 degrees. Fire extinguishers, carbon monoxide detector and smoke detectors are current and in compliance with fire safety requirements. LPA's observed centrally stored medications are kept locked and inaccessible to residents. LPA's reviewed and compared resident medication vs. resident medication logs.

LPA's reviewed 5 resident and 5 staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

A copy of report was left at facility and exit interview conducted with administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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