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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003017
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:02:06 PM

Document Has Been Signed on 05/09/2024 04:02 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:CARMICHAEL ESTATES NO. 3FACILITY NUMBER:
345003017
ADMINISTRATOR/
DIRECTOR:		MCFADDEN, REBECCAFACILITY TYPE:
740
ADDRESS:5216 EL CAMINO AVE.TELEPHONE:
(406) 501-5001
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
05/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Rebecca McFaddenTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 5/9/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual continuation visit from the annual inspection conducted on 4/9/2024. LPA met with Administrator and explained the purpose of the visit.

During today's visit, LPA and Administrator conducted a file review of residents and personnel files. LPA observed the required documents present.

LPA completed the care tool and no deficiencies cited today.

At this time, LPA is requesting facility Liability insurance to be emailed to LPA by Monday May 13, 2024.

Exit interview and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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