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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002929
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:57:30 PM

Document Has Been Signed on 10/12/2022 01:57 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
10/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Karl Ramos TIME COMPLETED:
02:05 PM
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On 10/12/2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility and met with Administrator, Karl Ramos, to conduct Pre-licensing inspection.

LPA toured the interior and exterior of the facility with Administrator. Fire extinguisher is current. The facility has (6) six residents bedrooms and six (6) bathrooms. LPA observed required furniture, and lighting throughout the facility. LPA observed knives/ sharps area were locked. LPA observed toxic and cleaning supplies locked in the laundry room. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Bathrooms are clean, sanitary, and in good repair. The hot water temperature was measured in the kitchen at 105 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer. LPA observed centrally stored medications area were locked and inaccessible to residents in care.

LPA observed one (1) fire extinguisher, smoke and carbon monoxide detectors in the facility. Licensing complaint poster are posted as required.

Component III presentation conducted with Administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with administrator.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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