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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000594
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:32:15 PM

Document Has Been Signed on 05/10/2022 03:32 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DE VENECIA GUEST HOME IIIFACILITY NUMBER:
347000594
ADMINISTRATOR:DE VENECIA, ESTRELLITAFACILITY TYPE:
735
ADDRESS:8414 CENTER PARKWAYTELEPHONE:
(916) 519-6331
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Estrellita De VeneciaTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Jamie Ivey Canady and Licensing Program Manager (LPM) Stephenie Doub arrived to the facility unannounced o conduct a Required Annual Inspection on 05/10/2022 at 2:33 pm. LPA and LPM were allowed entry into the building and met with Estrellita De Venecia administrator regarding today's visit. All the residents were present during this visit.

Administrator certificate expires 08/15/2022.

LPA toured and inspected the physical plant inside and outside to ensure all passageways, and other areas of potential hazard are free of obstruction. LPA observed the kitchen and dining area for the ability to prepare food. LPA observed, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 109*F which is within the required range of 105-120*F.. 
The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s), smoke detectors and pull alarm system Smoke dectectors and Carbon Monoxide detectors were tested and operational. Facility has central heating and air.
Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed during this visit. Exit interview held, copy of report given..
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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