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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002325
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:48:23 PM

Document Has Been Signed on 04/18/2024 02:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DAVID LEROY MANORFACILITY NUMBER:
115002325
ADMINISTRATOR/
DIRECTOR:		ELDER, NICOLEFACILITY TYPE:
735
ADDRESS:6362 COUNTY ROAD 24TELEPHONE:
(530) 356-5011
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 6CENSUS: 5DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Adminstrator- Nicole Elder TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 04/18/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Nicole Elder and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed each bedroom to have the required furnishings, windows with screens and working lights. LPA observed chemicals and medications locked and inaccessible to residents. LPA observed the kitchen well stocked with a variety of options for residents to choose from. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 114 F.

LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for emergency use. LPA observed a completed emergency disaster plan and emergency drills conducted.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and three (3) staff files which contained all of the required documentation.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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