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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340309927
Report Date: 10/07/2021
Date Signed: 11/04/2021 02:56:50 PM

Document Has Been Signed on 11/04/2021 02:56 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:PRISCILLA CARBONELL'S CARE HOMEFACILITY NUMBER:
340309927
ADMINISTRATOR:CARBONELL, PRISCILLAFACILITY TYPE:
740
ADDRESS:NO. 1 TIMBERWOOD COURTTELEPHONE:
(916) 929-4566
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 6CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jessica JarrellTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 10/07/2021 at 10:20 AM. LPA met with Jessica Jarrell and Priscilla Carbonell and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for four non-ambulatory residents and 2 ambulatory residents . There are currently 4 residents who reside at this facility.

LPA Martinez toured the facility with the Jessica Jarrell on 10/07/2021 at 10:30 AM.

The facility has one main entry screening point. All residents, essential visitors, and other visitors are screened before entering the facility. The screening consists of temperature checks, hand hygiene, and Covid-19 precautionary questions. The facility staff has received donning and doffing training. The facility has a 30 day supply of PPE, and has a designated infection control lead. Facility staff also conduct daily disinfecting cleaning. The facility has Covid-19 postings throughout the facility. The facility is practicing social distancing during meals and activities, and throughout the day. The facility has submitted a LIC 808 Mitigation Plan to Community Care Licensing Department (CCLD).

The interior of the facility is sanitary, and the exterior of the facility is clear of debris. The facility fire extinguishers are in good repair. The facility has an adequate supply of food. The facility had a comfortable temperature during the visit.

There were no deficiencies observed or cited at this annual inspection visit. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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