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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005717
Report Date: 08/30/2023
Date Signed: 08/30/2023 10:34:31 AM

Document Has Been Signed on 08/30/2023 10:34 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
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: 5DATE:
08/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Fernando ParamoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Health and Safety Check Case Management visit on 8/30/23 at 8:30am. LPA met with Fernando Paramo, Licensee and stated the purpose of the visit.

LPA and Fernando Paramo spoke about that status of the relocation application and documents.

Licensee stated that the documents were mailed to the office on yesterday which should arrive today. LPA observed the UPS receipt during this visit. LPA contacted the Analyst with the application unit to inform that the documents should arrive today.

Licensee stated that the fire pre-inspection was conducted and as far as he knows they submitted to CCL.

LPA observed all 5 residents having breakfast, and in good spirits during this visit.

LPA observed there are 0 residents receiving hospice care services and 0 bedridden residents at this time.

LPA observed that the property management has changed the front door and some work on the AC which is still not working during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited during this visit. Exit interview held, copy of report given.
Stephen Richardson
Victoria Brown
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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