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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701198
Report Date: 08/09/2024
Date Signed: 08/13/2024 09:56:00 AM

Document Has Been Signed on 08/13/2024 09:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BRENDA'S PLACEFACILITY NUMBER:
392701198
ADMINISTRATOR/
DIRECTOR:		MCCARTHY, BRENDAFACILITY TYPE:
740
ADDRESS:408 VALDAPENA COURTTELEPHONE:
(209) 403-2944
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY: 6CENSUS: 5DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Brenda McCarthyTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Unannounced annual visit made out to this facility on 08/09/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person, Jennifer Dietzel, who went ahead and got the facility designated Administrator at this time.
The facility designated Administrator, Brenda McCarthy, was present in the facility at this time for today's annual visit.
Current census was 5 residents.
It was learned that there were (2) residents under the care of hospice at this time.
It was learned that there was (1) resident receiving services through home health at this time.
It was learned that there were (2) residents diagnosed with dementia at this time.
Facility staff files were supplied by the facility designated Administrator for review at this time. This LPA also requested for the facility resident files at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located in the walkway leading to the garage area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, # 6017049740 for Brenda McCarthy, was observed to have an expiration date of 07/18/2024 at this time. It was learned that all required forms and documents have been submitted into the responsible entity for renewal at this time. These documents were submitted prior to the expiration date.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BRENDA'S PLACE
FACILITY NUMBER: 392701198
VISIT DATE: 08/09/2024
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Medication cabinet, located in the facility entry way drawers, were observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication area, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers (3), located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Jorgensen Co., and found to be in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility staff file was conducted and noted on the following LIC 859.
The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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