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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700469
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:16:39 PM

Document Has Been Signed on 10/22/2024 03:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GREAT HAVENFACILITY NUMBER:
342700469
ADMINISTRATOR/
DIRECTOR:
EZE, CHINYEREFACILITY TYPE:
740
ADDRESS:71 GROTH CIRTELEPHONE:
(916) 833-6388
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 6CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:04 PM
MET WITH:Chinyere, Eze, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On October 22, 2024, Licensing Program Analyst, (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an Annual Inspection. LPA met with the Licensee, Chinyere Eze, and informed her the reason for the visit. The Administrator certificate expires 8/8 2025. Licensee has not received her renewal certificate as of yet. The temperature in the facility was 77 degrees F.
LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, bathrooms, and kitchen. This is a 3 bedroom/2 bathroom 1 story home. Bathrooms and bedrooms were clean and in good repair. There is a locked storage cabinet for medications and toxins which is kept inaccessible. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire extinguishers are good as well as the carbon monoxide detector. LPA found the first aid kit to be complete.

LPA reviewed 2 resident records and 1 staff records. Resident files were complete and current. A review of staff records indicates facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

LPA and the licensee completed the infectious control questionnaire with no issues or concerns. Licensee have not had Covid-19 in the facility. No residents were available to be interviewed.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.An exit interview was conducted and a copy of this report was given to Chinyere.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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