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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002739
Report Date: 06/16/2021
Date Signed: 06/16/2021 11:29:10 AM

Document Has Been Signed on 06/16/2021 11:29 AM - 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:MARIA TERESA HOME CAREFACILITY NUMBER:
347002739
ADMINISTRATOR:SANCHEZ, MARIA TERESA R.FACILITY TYPE:
740
ADDRESS:7732 GYAN WAYTELEPHONE:
(916) 681-4133
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 4DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Maria Teresa SanchezTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 06/16/2021. LPA met with Administrator Maria Teresa Sanchez and explained the purpose of the visit. Maria Teresa Sanchez is the Administrator and holds certificate #6009456740 that expires on 12/16/2021

This facility is a single story building licensed to serve six (6) non-ambulatory residents. Facility is approved for (4) hospice residents at any time. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (113.2) degrees Fahrenheit in the kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 02/08/2021. Thermostat observed at (78) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.
The following forms were obtained during today's visit on 06/16/2021:
LIC 308
LIC 500
LIC 610

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during today's visit. Exit interview held with Maria Teresa Sanchez and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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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