<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550312394
Report Date: 06/05/2023
Date Signed: 06/06/2023 10:27:36 AM

Document Has Been Signed on 06/06/2023 10:27 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CIRCLE HOMEFACILITY NUMBER:
550312394
ADMINISTRATOR:DUNHAM, CHRISTINEFACILITY TYPE:
735
ADDRESS:15301 TUOLUMNE ROADTELEPHONE:
(209) 532-5411
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 4CENSUS: 2DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christine Dunham, AdminsitratorTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/05/23, at 10:30 AM, an unannounced annual inspection was conducted by Licensing Program Analyst, (LPA) Kimberly Viarella at this facility. LPA identified herself and the purpose of her visit to the Designated Facility Administrator, Christine Dunham, (Administrator's Certificate # 6025107735, expiration date 2/24/2023. LPA was shown a check dated 2/20/23 for $120.00.) A brief interview followed. At the time, census was 2.

The tour began in the kitchen. LPA checked the food supply and found that there were enough groceries for 2 days of perishable and 7 days of non-perishable items at this time. All opened items were labeled and dated. LPA did not observe any expired items at this time. Knives were secured in a locked drawer and chemicals were stored in a locked cabinet and separate from the food supply. Menus were posted on the refrigerator, as was the emergency drill log. The last drill was conducted in May 3, of 2023.

A new fire extinguisher was purchased on June 5, 2023 and the receipt was attached to the side for review.

The LPA observed the furniture, furnishings and lighting in the kitchen/dining area, family room, game room, and 2 bedrooms. All were in compliance. LPA measured the hot water to ensure it was between the range of 105-120 degrees as required. LPA observed that the 2 bathrooms in the house with color coded towels and linens for the 2 residents. LPA inspected the linen supply and found it to be sufficient for the residents in care.

Residents had access to over 120 (300 Piece) puzzles along with board games and a computer station with double monitors. Other activities include Peaceful Market on Saturdays, the Amusement Center in Black Oak Casino, the puzzle exchange at the library, and they also participate in the Watch Adult Day program. Outdoor activities include feeding and grooming the lamas that live at Circle Care Home.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CIRCLE HOME
FACILITY NUMBER: 550312394
VISIT DATE: 06/05/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA inspected resident medications which were kept in a locked box in a cabinet in the bathroom. There were no refrigerated narcotics/medications at this time. LPA compared medications to CMDR and found that everything was in compliance. LPA reviewed processes and procedures regarding storage, administration and destruction of medications.

LPA completed a records review for the 2 residents in care and 2 of the staff. LPA noted that files were in compliance. LPA checked verified the cash resources as well as the personal inventories for residents in care.

LPA conducted an inspection of the exterior of the facility. There were no bodies of water. There were no deficiencies noted at this time.

There were no deficiencies observed or cited during this annual inspection.

LPA conducted an exit interview with the Licensee/Administrator Christine Dunham and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2