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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700955
Report Date: 03/04/2021
Date Signed: 03/04/2021 10:20:33 AM

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:ELITE ELDER CAREFACILITY NUMBER:
092700955
ADMINISTRATOR:GERGI, EDUARDFACILITY TYPE:
740
ADDRESS:2041 BATES CIRTELEPHONE:
(916) 807-4319
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 6DATE:
03/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eduard GergiTIME COMPLETED:
10:30 AM
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Pre-licensing visit conducted today by Michael Smith LPA and licensee/administrator Eduard Gergi. There are no residents. Facility was granted fire clearance on 11/5/20 for a total of 6 residents, in which 5 can be non -ambulatory and 1 can be bedridden. Bedridden room #6 is cleared for bedridden. Facility will serve 6 senior residents ages 60 and over. Administrator’s certificate expires on 2/12/22.

Facility was inspected both indoors and outdoors. Outdoors was clean, tidy with adequate shading. Indoors has the requisite rooms for activity/den/dining. There are locked cabinets for personnel and client records. Facility has a First Aid kit and centrally stored locked cabinet for medication. Facility has appropriate linens for the bedrooms and baths. Bedrooms have the appropriate furnishings, chair, adequate lighting and storage. Water faucets are marked hot and cold with the hot water temperature at 109'. Smoke detectors were present. Fire extinguisher indicator revealed a full charge. Toxins and chemicals are appropriately locked in a cabinet. No hazardous debris noted.

All adults ages 18+ who reside here and are not clients, and all staff shall be fingerprinted and pass a criminal background check, prior to being present at the facility.

Licensee completed Component II on 2/25/21. Component III is being waived at this time, as the applicant has another facility in good standing, Love You Mom LIC #342700142.

This report will be forwarded to the centralized application unit for continued processing.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 206-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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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