<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005717
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:15:09 PM


Document Has Been Signed on 10/11/2022 03:15 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:KEVINBERG CARE HOMEFACILITY NUMBER:
347005717
ADMINISTRATOR:PARAMO, FERNANDOFACILITY TYPE:
740
ADDRESS:5725 KEVINBERG DRIVETELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Fernando ParamoTIME COMPLETED:
12:30 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
Licensing Program Analysts (LPA) Jamie Ivey Canady arrived unannounced to conduct a Required Annual Inspection on 10/11/2022 at 11:00 am. LPAwere allowed entry into the building. LPAs met with Fernando Paramo, administrator regarding today's visit. All the residents were present during this visit.
Administrator certificate is up to date and expires 12/27/2022 # 6022894740.
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 a crack on the kitchen floor and technical assistance was provided.  LPA observed, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. The temperature inside the building measured at 85 *F which is within the required range of 68-85*F. The hot water temperature was measured at 76*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. Facility has central heating and air.
At 11:15 am two resident files and two staff files were reviewed during this visit. Resident files are up to date with LIC602 for R1 dated 8/21/2022.
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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1