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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700400
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:58:23 PM

Document Has Been Signed on 01/10/2023 02:58 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:HEMPSTEAD HOMEFACILITY NUMBER:
342700400
ADMINISTRATOR:ROODENBURG, FRANSFACILITY TYPE:
740
ADDRESS:3105 HEMPSTEAD RDTELEPHONE:
(916) 485-7420
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY: 6CENSUS: 4DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Milagros DiosoTIME COMPLETED:
03:10 PM
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On 1/10/23 at 1:05PM Licensing Program Analyst (LPA) Chris Hopkins arrived at Hempstead Home for the purpose of conducting an unannounced required 1 year annual inspection. LPA met with Licensee, Milagros Dioso and together conducted a tour of the home.

LPA and Licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.
LPA measured the water temperature, temperature measured at 107 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing signs and COVID-19 informational signs posted throughout the facility. The facility has a designated infection control lead. The facility is able to designate and dedicate a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and copy of Liability Insurance.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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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