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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701338
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:34:25 PM

Document Has Been Signed on 10/30/2024 04:34 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR/
DIRECTOR:
PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 3DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:34 PM
MET WITH:Fernando ParamoTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 10/30/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Fernando Paramo (Administrator certificate # 6022894740, expiration date of 12/27/24) and a brief interview followed.

LPA began inspection in the kitchen. LPA observed all sharps and medications were locked and inaccessible to residents in care. LPA observed enough food items for 7 days perishable and 2 days non-perishable. LPA inspected all 3 resident bedrooms and found that they each had the required furniture, furnishings, and lighting to be in compliance at the present time.

The fire extinguisher was last inspected on 03/18/24 by Fire Code Equipment Safety Co. The hot water temperature was measured to ensure it was between 105 and 120 degrees Fahrenheit. The hot water measured 119.8 degrees and was in compliance at the time of inspection.

LPA reviewed medications, Centrally Stored Medication Record, and the Daily Medication Log along with ensuring the first aid kit had all the required items to be in compliance.

This LPA then conducted an inspection of the exterior of the facility. There were no bodies of water present and the back yard was completely fenced in. There was a shaded area with furniture for residents to enjoy. All windows and screens were in good repair at the time of inspection.

LPA reviewed the resident files for the 3 residents in care to ensure that they contained the required documents. LPA then reviewed staff files to ensure all required materials were included and that all care staff had their back ground clearances.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 10/30/2024
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According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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