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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003020
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:11:55 PM

Document Has Been Signed on 05/18/2023 04:11 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. 1FACILITY NUMBER:
345003020
ADMINISTRATOR:DELUCA, ALEJANDRAFACILITY TYPE:
740
ADDRESS:5228 EL CAMINO AVETELEPHONE:
(406) 533-8372
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
05/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rebecca McFaddenTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a Pre-licensing inspection for the change of ownership. LPA met with Administrator, Rebecca McFadden. LPA wore the following Personal Protective Equipment: surgical mask.

During today's visit, LPA observed four (4) residents to be present in their rooms, and one (1) resident was out of the facility during the time of inspection. Currently one (1) resident on hospice services. This application is a change in ownership. Facility has a clearance for six (6) non-ambulatory residents.

LPA and Administrator toured the interior and exterior of the facility. Areas toured included but not limited to: common areas, office, resident bedrooms, bathroom, kitchen, staff room, and backyard. LPA observed medications to be centrally locked and stored in the office. LPA observed residents file to be locked and stored in the office. LPA observed cleaning products and other toxins to be locked away. LPA observed knives and sharps found to be locked and secured in the kitchen. Fire extinguisher was last serviced 3/3/2023. LPA observed the facility to have adequate food supplies, 7+ days of non perishables and 2+ days of perishables. LPA observed the facility to have the required postage on the wall. LPA and Administrator complete the prelicensing tool together, and found the facility to be at compliance.

Component III was waived during today’s inspection as Applicant David Deluca was recently Administrator certified and a previous licensee. Additionally, Administrator Rebecca McFadden, will remain at the facility.

Applicant satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection.

A copy of this report was provided to the facility. Exit interview conducted.
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)
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