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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003017
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:13:04 PM

Document Has Been Signed on 05/18/2023 04:13 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:CARMICHAEL ESTATES NO. 3FACILITY NUMBER:
345003017
ADMINISTRATOR:MCFADDEN, REBECCAFACILITY TYPE:
740
ADDRESS:5216 EL CAMINO AVE.TELEPHONE:
(406) 501-5001
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
05/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David DelucaTIME 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
Licensing Program Analyst (LPA) Cassie Yang arrived announced and met with Applicant, David Deluca. LPA explained the purpose of the visit is to conduct Pre-licensing inspection. LPA wore the following Personal Protective Equipment: surgical mask. LPA observed six (6) residents to be present in their rooms. Currently one (1) resident on hospice services. This application is a change in ownership. Facility has a clearance for five (5) non-ambulatory and one (1) bedridden.

LPA and Deluca toured the interior and exterior of the facility. Areas included but not limited to: common areas, kitchen, resident bedroom, bathrooms, staff room and backyard. LPA was informed that residents are in bed, taking a nap before brunch. LPA observed the facility to have adequate food supplies, 7+ days of non perishables and 2+ days of perishables.

LPA observed hot tap water to be at 111*, LPA observed the temperature of the facility to be 71* During today's inspection, LPA observed the fire extinguisher to be serviced 3/3/2023, and facility's carbon monoxide and smoke alarms to be operable. LPA observed a new First Aid kit, PPE supplies and linens. LPA was provided proof of pest extermination, last serviced 5/11/2023.

LPA discussed resident paperwork to be completed upon ownership change. LPA observed various required postings. LPA observed Theft & Loss Policy, blank admission agreement and visitation policy is posted in facility public binder.

Component III was waived during today’s inspection as Deluca was recently Administrator certified and a previous licensee. LPA will notify the applications unit the facility is in substantial compliance.

Exit interview conducted and a copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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 1