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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000716
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:13:03 PM


Document Has Been Signed on 07/29/2024 01:13 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:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Farah CucciaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Todd Tryon visited the facility on July 29, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the CARE Tool was used. LPA reviewed 5 resident and 4 staff files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is compliant with fire drills. LPA interviewed 1 resident; others not interviewed due to dementia.

LPA and Farah toured the facility including resident rooms, common areas, backyard, kitchen, pantry and medication room. Food supplies appeared adequate to meet the requirement of 2 days perishable and 7 days non-perishable food. Medications are centrally stored, locked and logged. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the facility's current liability insurance. Most recent LIC610E and Infection Control Plan are already on file at CCL.

No deficiencies cited. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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