<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701650
Report Date: 11/20/2025
Date Signed: 11/20/2025 11:01:57 AM

Document Has Been Signed on 11/20/2025 11:01 AM - 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:ANTONINA'S CARE HOMEFACILITY NUMBER:
342701650
ADMINISTRATOR/
DIRECTOR:		CARIDAD, JAYSONFACILITY TYPE:
740
ADDRESS:8712 BRAY VISTA WAYTELEPHONE:
(916) 685-0404
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
11/20/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Jayson and Amy CaridadTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/20/2025, Licensing Program Analyst (LPA) Sommer Hayes arrived announced regarding a prelicensing inspection. This pre-licensing is for Change of Ownership (CHOW). LPA met with Administrator Jayson Caridad and Licensee Amy Caridad.

LPA Hayes inspected the physical plant of the facility to ensure compliance of Title 22 regulations. LPA Hayes observed 5 resident bedrooms, the activity room, dining room, kitchen, and outdoor areas. The facility is a one-story building. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA Hayes did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bodies of water were not observed at this time.

Resident Bedrooms: LPA inspected 5 resident bedrooms. Each bedroom is fire cleared for non-ambulatory residents. The resident bedrooms are spacious and observed to be furnished with adequate storage for resident belongings. The water temperature was measured at 113 degrees Fahrenheit (F).

Bathroom: All bathrooms inspected have working toilets, wash basins and showers and bath tubs.

Toxins and Chemicals: Toxins and chemicals for cleaning are properly stored, locked, and inaccessible to residents in care.

continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
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: ANTONINA'S CARE HOME
FACILITY NUMBER: 342701650
VISIT DATE: 11/20/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Food Service and Kitchen: The kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils are locked and inaccessible to residents. The food supply was adequate and stored in the kitchen refrigerator and kitchen cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. The date of purchase was written on food items in the refrigerator and freezer. Stove burners and oven were observed to be in good repair.

Smoke Detectors/Carbon Monoxide: Smoke detectors are hardwired and interconnected, and they are fully operational. The facility conducts quarterly smoke alarm testing. The most recent fire drill occurred 09/09/25 and 09/10/25 that included all residents and 5 staff.

Medications and First-Aid Kit: Resident medications were observed to be stored in the medication room and locked and inaccessible to residents in care. The first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in the locked medication room.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. The applicant has passed the pre-licensing component III of the application process. LPA Hayes will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report has been provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3