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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701286
Report Date: 06/30/2023
Date Signed: 06/30/2023 12:10:51 PM

Document Has Been Signed on 06/30/2023 12:10 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BEATRICE HOME CAREFACILITY NUMBER:
342701286
ADMINISTRATOR:CLARK, BEATRICEFACILITY TYPE:
740
ADDRESS:1014 FERNANDO WYTELEPHONE:
(916) 270-3961
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 6CENSUS: 0DATE:
06/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Beatrice ClarkTIME COMPLETED:
12:15 PM
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On 6/30/23 at approximately 8:30am Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Jennifer Fain arrived to do an announced abbreviated pre-licensing inspection. LPA and LPM met with the Licensee / Administrator (ADM), Beatrice Clark, and explained the purpose of the visit.

LPM King inspected the items that needed correction from Prelicensing visit on 6/14/23 and all items were cleared. In addition, the following were reinspected to assure they met the requirements; fire alarm and Co2 sensors, food supply and inaccessibility of toxins. LPA Fain checked the water temperature which was measured at 107.04* F. LPA and LPM observed the fire door leading to bedroom 4 and the backyard had been removed. Ambulatory status was updated to 1 ambulatory and 5 non-ambulatory. Bedroom 4 is cleared for ambulatory only.

The Inspection Tool was completed during this visit.

The facility was determined to be in substantial compliance with the Health and Safety Code and the California Code of Regulations. The facility has passed the pre-licensing inspection. Component III was conducted.

In addition, the LPA provided Technical Assistance (TA) to the Licensee / ADM on areas incl. medications, hospice and the Technical Assistance Program (TSP) and provided copies of: LIC624, LIC9020, LIC311F, COMP III, Hospice Resource Guide, TSP Brochure and the Medications Guide.


An exit interview was held and a report was given to Administrator Beatrice Clark


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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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