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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000716
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:17:36 PM


Document Has Been Signed on 08/10/2023 02:17 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:ELIM GLENFACILITY NUMBER:
317000716
ADMINISTRATOR:LEE, EDWARD INCHULFACILITY TYPE:
740
ADDRESS:6257 EUREKA ROADTELEPHONE:
(916) 791-9451
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:20CENSUS: 20DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Farah CucciaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday August 10, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (5) and staff (6) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills.

LPA and COO Farah toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, common areas, backyard, kitchen, pantry and medication room. LPA observed the facility's PPE supply. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPA obtained a copy of the facility's current liability insurance. COO will email LPA an updated copy of LIC610E and Infection Control Plan by end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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