550312394-6-12-2025-27-AS-ELIM-DHKSKB-20250612135629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 550312394
Report Date: 06/12/2025
Date Signed: 06/12/2025 01:56:55 PM

Document Has Been Signed on 06/12/2025 01:56 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 HOME		FACILITY NUMBER:	550312394
ADMINISTRATOR/ DIRECTOR:	DUNHAM, CHRISTINE		FACILITY TYPE:	735
ADDRESS:	15301 TUOLUMNE ROAD		TELEPHONE:	(209) 532-5411
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY: 4		CENSUS: 2	DATE:	06/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Christine Dunham, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 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 06/12/2025 at 11:00 AM, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived at the facility unannounced to conduct a required annual inspection and was greeted by the Designated Facility Administrator (DFA). The LPA and LPM identified themselves and explained the purpose of the visit. The purpose of the visit was to conduct a required annual inspection. The DFA accompanied the LPA on a tour of the physical plant, including inside and outside areas, to ensure that there are no health and safety hazards. The inspection tool was used during this site visit. This facility is a 2-story residential home. The facility has a capacity of four and currently has two residents in care. The residents occupy the two bedrooms, two bathrooms, and common areas on the bottom floor. The facility has two staff, who occupy the living quarters on the second floor. The facility is vendorized by Valley Mountain Regional Center as a Level 3 facility. ENTRY ROOM/LAUNDRY: At 11:17 AM, the LPA entered the facility and toured the entry room, which contained the washer and dryer. The LPA observed a fire extinguisher hanging on the wall, which was purchased at Lowes on 4/28/2025. KITCHEN and DINING ROOM: At 11:23 AM, the LPA toured the kitchen. The kitchen counters, sink, floor, and appliances are clean, operable, and odor- and pest-free. The facility has the required supply of perishable and nonperishable food located in the refrigerator, freezer, and cupboards. Sharp objects are stored in a drawer with a lock, which can be locked if needed. This is not required for the current residents. A small two-person dining table is located in the kitchen and there is a kitchen island with three stools at it. The thermostat is set at 73 degrees Fahrenheit. The facility’s disaster drill logs are located on the side of the refrigerator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CIRCLE HOME	FACILITY NUMBER: 550312394
	VISIT DATE: 06/12/2025

NARRATIVE

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LIVING ROOM: At 11:35 AM, the LPA toured the living room. The living room is clean, with many windows that let in natural light, braided area rugs, a television, and enough seating for both residents. There is a puzzle table, with tens of puzzles stored underneath it.

HALLWAY/STORAGE CLOSET: At 11:38 AM, the LPA toured the hallway. The hallway contained two smoke/carbon monoxide detectors. The DFA tested both and both are operational. The LPA observed a storage closet in the hallway, which contained linens for the residents, a first aid kit with all the required elements, and emergency lighting and extra batteries.

HALLWAY BATHROOM: At 11:45 AM, the LPA toured the hallway bathroom. It was clean and odor-free. The
hot water temperature at the bathroom sink is 106 degrees Farenheit. There is counter and drawer space for residents’ hygiene products.

CENTRAL MEDICATION STORAGE AREA: At 11:55 AM, the LPA inspected the facility's central medication
storage area. Medications are contained in a locked box located in a lower cabinet in the bathroom. Each resident’s medication is stored in a separate bag inside the locked box. All medications are in their original containers with labels intact. The LPA observed the paper based Medication Administration Record, which was complete and up-to-date.

BEDROOMS: At 12:00 PM, the LPA toured the two resident bedrooms. While both bedrooms contained two beds, both rooms were currently single occupancy. Each bedroom also contained a dresser, a night stand, cabinets, and a desk in good repair. There are many windows in each room that let in natural light. The closets are organized, clean, and odor-free. The flooring is unblemished. One bedroom has a private bathroom, which was clean and odor-free.

YARD: At 12:10 PM, the LPA toured the front and side yard. The LPA observed a grassy area shaded by trees outside the main door, with outdoor furniture in good repair. The facility is located on a llama farm. There were llamas in several pens located around the house. The residents help care for the llamas daily. The trees, grass, and flowers are manicured and the pathways are unobstructed.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CIRCLE HOME	FACILITY NUMBER: 550312394
	VISIT DATE: 06/12/2025

NARRATIVE

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RECORD REVIEW: At 12:25 PM, the LPA and LPM reviewed the facility records for the two staff and two residents. Staff records included the required health screening, proof of initial and annual training, and first aid certification. The LPA confirmed that all current staff are associated with this facility and have a criminal background clearance, according to Guardian. Resident records included the required preplacement appraisals, admission agreements, and annual physician reports. Disaster drills are held monthly and the log indicated who attended the drill and what type of disaster was covered.

The Administrator has applied for renewal of their Administrator Certificate, which is currently pending.

The LPA requested that updated copies of these documents be submitted to the Department by 5:00 PM on
on 06/19/2025.

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(3) LIC 610 Current Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) LIC 500 Current Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, the facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. There were no deficiencies at this time.

An exit interview was conducted with the DFA, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

LIC809 (FAS) - (06/04)

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