340317187-4-27-2023-59-AS-DAWL-CRAS5P-20230427133441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340317187
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:34:52 PM

Document Has Been Signed on 04/27/2023 01:34 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME:	G.M. ROJO GUEST HOME		FACILITY NUMBER:	340317187
ADMINISTRATOR:	ROJO, MADELYN M.		FACILITY TYPE:	740
ADDRESS:	5637 WHITE FIR WAY		TELEPHONE:	(916) 344-8072
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	6	CENSUS: 5	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Madelyn Rojo, Administrator		TIME COMPLETED:	01:44 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 27, 2023, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required annual inspection. LPA met with , Administrator Madelyn Rojo and explained purpose of inspection. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Maria and LPA completed the inspection tool questionnaire with no issues or advisories to report. LPA observed the following: Administrator certificate is valid. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Water temperature measured 113 degrees F. Medication was properly stored and locked away. LPA reviewed 2 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts and background checks were all up to date. The facility is conducting staff training as required. To continue see 809-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: G.M. ROJO GUEST HOME	FACILITY NUMBER: 340317187
	VISIT DATE: 04/27/2023

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As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

Administrator submitted the following documents to update the Regional Office files on Community Care Licensing
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
-copy of liability insurance
-updated facility sketch
The will be due May 27, 2023

Exit interview conducted and a copy of this report given to Madelyn

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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