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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701187
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:39:40 PM

Document Has Been Signed on 09/30/2024 03:39 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WELCOME HOMEFACILITY NUMBER:
502701187
ADMINISTRATOR/
DIRECTOR:		VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:1602 CHARLOTTESVILLE LANETELEPHONE:
(209) 312-9352
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 6CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Brandi Vargas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Brandi Vargas, Administrator and explained the purpose of the visit.

The facility is a single story residence licensed for a capacity of 6 non-ambulatory elderly residents with a hospice waiver for 6 elderly residents. LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas to ensure there are no safety hazards for residents. Furniture and furnishings were sufficient to meet the needs of residents. As observed by LPA Campbell, there are three clients residing in the facility. The facility has three bedrooms and two bathrooms. All bedrooms contain a bed, night stand, lamp and closet for each resident.

The facility temperature was 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature in the bathroom was measured at 108 degrees Fahrenheit and 118 degrees in the kitchen which is within the required range of 105 and 120 degrees. The backyard was toured by LPA Campbell and pathways and exits were found to be clear. A locked shed was observed in the backyard containing yard equipment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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: WELCOME HOME
FACILITY NUMBER: 502701187
VISIT DATE: 09/30/2024
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In the metal cabinet in the dining area, LPA Campbell observed first aid supplies with bandages, scissors, tweezers and a manual. A thermometer was stored in the same cabinet along with client medications and sharps. There was a fully-charged and up-to-date fire extinguisher that was last inspected on 06/19/2024 by the entry to the garage. The carbon monoxide/smoke detectors were tested successfully during the visit. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food.

There are currently three staff in all for the facility. All three staff have been fingerprint cleared to work in the facility. Of the three staff, all three of their files were reviewed. All three of the client files for the three clients in the facility, were reviewed as well. Staff present in the facility were interviewed as required for the CARE Tool.

LPA Campbell observed a Water Temperature Log for the facility and the Residential Infection Control Plan kept on file. A "See Something Say Something" Poster was observed at the entrance to the garage.

LPA Campbell consulted with facility regarding dating newly purchased condiments, highlighting the hire date on client checklists and using a lock that was more easily accessed to encourage consistent locking practices.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Brandi Vargas, Administrator and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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