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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002917
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:21:24 PM

Document Has Been Signed on 09/28/2023 02:21 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:KIMBERLY'S FAMILY HOMEFACILITY NUMBER:
585002917
ADMINISTRATOR:KENNEDY, KIMBERLYFACILITY TYPE:
735
ADDRESS:1907 8TH AVETELEPHONE:
(530) 301-7820
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 4CENSUS: 4DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Kim KennedyTIME COMPLETED:
02:30 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Administrator Kim Kennedy.

This main entrance opens to the main sitting room. The kitchen, nook, and office with a full bathroom are to the right of the main entrance. There is a staff bedroom next to the nook area. There is a hallway that leads to the back of the facility. The hallway leads to four private resident rooms and one sitting area. The sitting area has a full bathroom. There is an exit in the sitting are as well. The backyard has a shed in one corner.


Two resident files and two staff files were reviewed.

Several topics were discussed

The following shall be updated and submitted to Community Care Licensing by 10/15/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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