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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700016
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:27:54 PM


Document Has Been Signed on 07/11/2023 04:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:RESTPADD CARE LLCFACILITY NUMBER:
342700016
ADMINISTRATOR:NWANGBURUKA, IHEOMAFACILITY TYPE:
740
ADDRESS:6901 RIO TEJO WAYTELEPHONE:
(916) 685-3690
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Iheoma Nwangburuka, AdministratorTIME COMPLETED:
04:40 PM
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On 7/11/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Administrator Iheoma Nwangburuka and explained the purpose of the visit.

Administrator holds certification #6035025740 and is expired on 4/6/2023. Renewal application has been submitted and currently pending. The facility is licensed for 6 non-ambulatory residents. Approved hospice waiver for 1. There are currently 5 residents who reside in the facility and 1 resident who is currently at a skilled nursing facility.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises.
The hot water temperature was measured at 113.5*F which was within the required range of 105-120*F. The temperature inside the facility measured at 78*F which was within the required range of 68-85*F.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed.

LPA requested resident and staff files for review. LPA reviewed (6) resident files and (2) staff files, including criminal record clearances. LPA reviewed staff associations to the facility. A full Care Tool Inspection was completed at facility.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RESTPADD CARE LLC
FACILITY NUMBER: 342700016
VISIT DATE: 07/11/2023
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Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) Proof of current liability insurance
(2) LIC 500 Personnel Report
(3) LIC 610 Emergency Disaster Plan
(4) LIC 308 Designation of Administrative Responsibility

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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