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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003015
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:16:06 PM

Document Has Been Signed on 03/13/2025 01:16 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LITTLE BROOK CARE HOME 4FACILITY NUMBER:
345003015
ADMINISTRATOR/
DIRECTOR:		POP, PERSIDAFACILITY TYPE:
740
ADDRESS:4401 LITTLE BROOK CTTELEPHONE:
(916) 500-4512
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 0DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Pop Persida, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility on 3/13/25 to conduct a Required-1 Year Inspection utilizing the inspection tool.

There are no residents residing at the facility at this time. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA checked medication storage and found medication to be inaccessible.

LPA requested copy of liability insurance. Administrator will inform the Department upon admission of the first resident.

As of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted copy of report given at the conclusion of this visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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