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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003892
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:22:42 PM

Document Has Been Signed on 08/18/2023 01:22 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:CARE PROVIDERS AT ARDENFACILITY NUMBER:
347003892
ADMINISTRATOR:APUYA, MARY JANEFACILITY TYPE:
740
ADDRESS:4448 ARDEN WAYTELEPHONE:
(916) 489-1883
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY: 6CENSUS: 4DATE:
08/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Mary Jane Apuya - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit. LPA met with administrator and explained purpose of visit. Administrator certificate expires November 1, 2024.

LPA and administrator conducted a tour inside and outside the facility. LPA observed the back yard with secure fence and no pool or body of water observed. LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed bedrooms and living areas to be adequately furnished. The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.7*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s) last inspected on February 27, 2023, smoke and carbon monoxide detectors, and central heating and air in the facility. All Fire Exits are free of obstacles and last fire drill was completed on July 15, 2023. LPA observed two day perishables and seven day non-perishables.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items. LPA observed bathroom facilities to be functioning properly. Cleaning supplies and chemicals are stored in a locked cabinet. Medications and confidential paperwork are stored in a locked cabinet. Activity supplies available.
LPA reviewed two staff and two resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

LPA requested the following updated documents for master file to be submitted to CCL via email by August 25, 2023:
Designation of Facility Responsibility (LIC 308), Administrative Organization (LIC 309), Personnel Report (LIC 500), Emergency Disaster Plan (610-E), and Liability Insurance.
ruth.wallace@dss.ca.gov
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.
Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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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