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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701198
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:42:49 PM

Document Has Been Signed on 08/04/2022 12:42 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:BRENDA'S PLACEFACILITY NUMBER:
392701198
ADMINISTRATOR:MCCARTHY, BRENDAFACILITY TYPE:
740
ADDRESS:408 VALDAPENA COURTTELEPHONE:
(209) 403-2944
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY: 6CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brenda McCarthyTIME COMPLETED:
12:45 PM
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On 8/4/22 at approximately 9:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a pre-licensing inspection. LPA Jensen met with Licensee Brenda McCarthy and explained the purpose of today's visit. Licensee holds current Administrator's certificate # 6017049740 good through 7/18/2024.

The facility is a single story structure with an entrance for guests and a separate entrance for staff through the garage that also has ADA accessibility for residents if needed. Both entrances are equipped with sign in sheets. There is PPE available at both entrances. LPA Jensen toured the physical plant including but not limited to the garage, laundry room, 3 bathrooms, 3 bedrooms, kitchen and common areas. The facility was observed to be sanitary and free of odor. Night lights were observed in all hallways.

3 of 3 bedrooms are double occupancy. All bedrooms were observed to be furnished with dressers, chairs, lamps and night stands. There was an adequate supply of linens on hand. 2 of 3 bathrooms are equipped with grab bars at the toilet and in the shower. The living room contained adequate seating for 6 residents. There are two indoor activity areas in the facility. One activity area is located in the garage and the second is adjacent to the kitchen and living room. A variety of activities to encourage engagement and movement was observed on hand. The kitchen refrigerator and freezer were measured at temperatures that fall within regulatory requirements. Knives and chemicals were observed to be locked and inaccessible to prospective residents. The water temperature was measured at 114 degrees which falls within the required range. The laundry room was observed to have appliances in good repair and with chemicals locked and inaccessible to residents. Medication will be centrally stored and locked in the laundry room with a separate double locked safe for narcotics.

A first aid kit was observed to be complete with scissors, thermometer, tweezers, manual and various wound dressings. The fire extinguisher was serviced in May of 2022 and is in compliance. The fire alarm and carbon monoxide detector were tested and found to be in working order. There are no bodies of water on premises.
Continued on LIC 809C.......
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BRENDA'S PLACE
FACILITY NUMBER: 392701198
VISIT DATE: 08/04/2022
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Continued from LIC 809....
There is a fire place with an insert that is adequately screened. A separate refrigerator for medications that is locked was observed in the garage. All pathways were free of obstruction. All required signage was prominently posted in the facility. A facility sketch is posted in every room with an indication of where you are currently located. A mock resident file and mock personnel file were reviewed and were determined to contain all necessary regulatory components.

The grounds were well maintained and free of debris. LPA Jensen observed a patio set outside in the backyard with sufficient seating for all residents. All entrances/exits are equipped with motion sensors.

During today's inspection, this facility is in substantial compliance and meets the minimum requirements for RCFE licensure therefore the applicant has passed the pre-licensing inspection.

LPA and Licensee reviewed Component III. Component III has been completed with the Applicant.

An exit interview was conducted and a copy of this report was given to Licensee Brenda McCartty.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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