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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340309927
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:08:02 AM

Document Has Been Signed on 01/28/2022 11:08 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
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: 3DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica JarrellTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 01/28/2022. A risk assessment call was performed prior to entry. LPA met with Jessica Jarrell and explained the purpose of the visit. Jessica Jarrell is the back up Administrator and holds certificate #6036309740 that expires on 08/07/2023. Administrator Priscilla Carbonell was not present during the inspection but has a valid administrator certificate #6017005740 expires on 07/07/2022.

This facility is a single story building licensed to serve four (4) ambulatory and two (2) non ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (115) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers last serviced 03/29/2021. Thermostat observed at (68) degrees Fahrenheit.
LPA received an updated copy of the certificate of liability insurance and updated copy of Administrator certificate. All other documents are current and on file.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.
There were no deficiencies found during today's visit. Exit interview held with Jessica Jarrell and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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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