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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002917
Report Date: 08/08/2024
Date Signed: 08/09/2024 10:08:01 AM

Document Has Been Signed on 08/09/2024 10:08 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KIMBERLY'S FAMILY HOMEFACILITY NUMBER:
585002917
ADMINISTRATOR/
DIRECTOR:		KENNEDY, KIMBERLYFACILITY TYPE:
735
ADDRESS:1907 8TH AVETELEPHONE:
(530) 301-7820
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 4CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Kimberly KennedyTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 8/8/24 LPA Tryon visited the facility to conduct an annual inspection. LPA met with licensee Kimberly Kennedy. The facility currently has 4 residents.

LPA toured the facility with Mrs. Kennedy including common areas, kitchen, food storage, hallways, bathrooms, resident rooms, etc.

The home is clean and nicely furnished. Resident rooms are appropriately furnished. Smoke and carbon monoxide detectors installed. Fire extinguishers present and charged.

Food supplies appear to meet the requirement of 2 days perishable and 7 days non-perishable. Bathrooms are clean and fixtures are clean and functional. Medications are centrally stored and locked.

LPA reviewed Administrator staff file and 2 resident files. Files contain required documentation.

LPA reviewed the CARE Tool with Administrator.
No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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