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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000905
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:37:35 PM

Document Has Been Signed on 09/29/2022 02:37 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BENIE LUNGAN CARE HOMEFACILITY NUMBER:
347000905
ADMINISTRATOR:LUNGAN, BENILDAFACILITY TYPE:
740
ADDRESS:5420 SHORTWAY DRIVETELEPHONE:
(916) 394-9469
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 4DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Benilda LunganTIME COMPLETED:
02:28 PM
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On 9/29/2022 at 11:53 AM, LPA Jamie Ivey Canady arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by administrator Benilda Lungan. LPA was screened upon entry for COVID precautions. LPA explained the purpose of the visit to Benilda. Benilda accompanied LPA on facility tour.

LPA Ivey Canady inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms.

LPA Ivey Canady observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
Water temperature reads 112.9 F and the facility temperature registered at 77*F. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

Administrator Certificate Number 6003722740 assigned to Benilda B Lungan expires 5/4/2023.

The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked September 19, 2022. Facility has an emergency food and water supply in a separate storage area in kitchen. LPA requested, received and reviewed 2 Staff and 2 Resident Files.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Benie Lungan.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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