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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701464
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:51:53 PM

Document Has Been Signed on 08/23/2024 03:51 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:SIGNATURE LIVING ON SHADY RIVER CIRCLEFACILITY NUMBER:
342701464
ADMINISTRATOR/
DIRECTOR:
ENERO, EDGARFACILITY TYPE:
740
ADDRESS:51 SHADY RIVER CIRCLETELEPHONE:
(916) 812-0944
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Edgar EneroTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 8/23/24 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Signature for the purpose of conducting a required pre-licensing inspection. LPA met with applicant and together conducted a tour of the home.

LPA and applicant evaluated the physical plant to ensure the health and safety of future residents in care. Areas inspected are including but not limited to the kitchen, bedrooms, bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA did observe four (4) window screens with small tears or worn and are in need of replacement. 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 116.6 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications area secure from residents.

As of todays inspection the facility has not met all requirements to be licensed.

To be completed: replace/repair four (4) window screens on the back of the home.

Photos of corrections to be emailed to LPA. Once received LPA will documents and refer the facility to be licensed. Exit interview conducted and a copy of this report was left with the applicant.

Licensee currently operates licensed homes in substantial compliance with Title 22 regulations. Component III orientation has been waved, approved by LPA Kevin Gould.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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