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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920001
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:12:34 PM

Document Has Been Signed on 05/18/2023 04:12 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. 2FACILITY NUMBER:
345920001
ADMINISTRATOR:MCFADDEN, REBECCAFACILITY TYPE:
740
ADDRESS:5220 EL CAMINO AVE.TELEPHONE:
(406) 533-8373
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
05/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Alejandra DelucaTIME COMPLETED:
01:30 PM
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On 5/18/2023 at 11:15 AM, Licensing Program Analyst (LPA) Cassie Yang arrived announced and met with Alejandra 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 four (4) residents to be present in their rooms. Currently zero (0) 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 toured included but not limited to: common areas, resident bedrooms, staff bathroom, resident bathroom, staff room, kitchen, and backyard. LPA observed knives and sharps found to be locked and secured in the kitchen. LPA observed cleaning products and other toxins to be locked away. LPA observed smoke detectors and carbon monoxide detectors present at the care home. LPA was informed that resident files and medication were centrally stored at their facility next door. LPA observed 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 Theft & Loss Policy, blank admission agreement and visitation policy is posted in facility public binder. LPA observed the facility to not have the adequate required postage. Deficiencies were observed but corrected immediately.

Component III was waived during today’s inspection as co-Applicant David Deluca was recently Administrator certified and a previous licensee. Applicant has 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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