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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550312394
Report Date: 06/21/2024
Date Signed: 06/21/2024 02:01:31 PM

Document Has Been Signed on 06/21/2024 02:01 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:CIRCLE HOMEFACILITY NUMBER:
550312394
ADMINISTRATOR/
DIRECTOR:
DUNHAM, CHRISTINEFACILITY TYPE:
735
ADDRESS:15301 TUOLUMNE ROADTELEPHONE:
(209) 532-5411
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 4CENSUS: 2DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Christine DunhamTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 6/21/24 at approximately 11am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a required one year annual visit. LPA Jensen met with Administrator Christine Dunham and explained the purpose of today's visit. Christine has a current Administrator's certification number 6025107735 good through February 24th of 2025. There were no clients present at the time of this visit as they were attending Day Program. The inspection tool was used during the course of this visit.

LPA Jensen toured the grounds. The grounds are also home to a Llama Ranch. There is an outdoor area with patio furniture and shaded areas for outdoor activities. The Llamas have a separate fenced in area on the 3 acre property. LPA Jensen toured the facility interior. The physical plant is two story structure. The clients reside on the first level and the Licensees reside on premises with bedrooms on the second level. LPA Jensen toured the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. Knives, cleaning supplies and medications are locked and inaccessible to residents in care. The thermostat was set a comfortable temperature. LPA Jensen observed the furniture and lighting to be adequate. There is a sufficient supply of linens. There is a variety of activities available including animal care and puzzles.

The facility maintains an emergency supply kit that is compliant. There is a generator on site in the event of a power outage. The facility maintains emergency food, water and lighting. The fire extinguisher was purchased in June of 2024 and is in compliance. The carbon monoxide detector and smoke detector was tested ad determined to be in good working order.

LPA Jensen reviewed 2 of 2 resident files and determined them to be complete and in compliance. A random audit was conducted on P&I funds and the accounting was accurate. LPA Jensen verified that the liability insurance is current. The Licensees are currently the only two staff working at the facility and they have valid CPR certifications and background clearances. The annual fees are current. The facility was observed to be in substantial compliance. No deficiencies are being issued. An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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