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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700606
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:25:24 PM

Document Has Been Signed on 05/20/2022 03:25 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:LAND PARK PLACEFACILITY NUMBER:
342700606
ADMINISTRATOR:LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:6140 S LAND PARK DRIVETELEPHONE:
(916) 395-7773
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Erlinda SembranoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/20/22 at 3:00PM. Administrator certificates expires 2/20/2023.

LPA met with Erlinda Sembrano, 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 participating in a group activity during this visit. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 78*F which is within the required range of 68-85*F. The hot water temperature was measured at 115.6*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. Facility has a pull alarm system.

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)
Liability Insurance
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: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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