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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700087
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:11:58 AM

Document Has Been Signed on 05/19/2022 11:11 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:SOUTH LAND PARK HILLS RCFEFACILITY NUMBER:
342700087
ADMINISTRATOR:HOUSTON, ANGELINE KFACILITY TYPE:
740
ADDRESS:7340 BARR WAYTELEPHONE:
(916) 266-3030
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Agnes ArrizaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/19/22 at 10:52AM.

LPA met with Agnes Arriza Melchor, Caregiver and stated the purpose of todays visit. The facility is licensed for a capacity of 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents and visiting families during this visit.
LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 77*F which is within the required range of 68-85*F. The hot water temperature was measured at 110.1*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.
There are no residents receiving hospice services at this time.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Personnel Report (LIC500)
Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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