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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700016
Report Date: 07/29/2024
Date Signed: 07/29/2024 03:07:55 PM


Document Has Been Signed on 07/29/2024 03:07 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Iheoma NwangburukaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA met with facility staff Mila and explained the purpose of the visit. LPA was later met by Administrator Iheoma Nwangburuka.

LPA and facility staff toured the facility to ensure compliance with Title 22 regulations. LPA observed the resident bedrooms. The bedrooms were observed to have necessary furniture and furnishings, no odors, and to be organized. The bathrooms were observed to be clean and free from debris. The hot water measured at 106.4*F, which is within the regulatory range. The temperature inside the facility was at a comfortable temperature. The facility is equipped with an emergency supply of food and water, a supply of perishable foods for seven days, and a supply of non-perishable food for a minimum of two days. Fire extinguishers were observed to be in working condition. Medications, sharps, and cleaning supplies were observed to be locked away and inaccessible to residents in care. The backyard was observed to have an area for outside visits. The shed was observed to be empty and utilized for storage. No health or safety concerns observed. Staff was observed cleaning up lunch items, assisting residents with meals, assisting residents with ADLs, and doing exercise with residents. Residents were observed finishing up lunch, watching television, taking a nap, and engaging with staff.

LPA Valerio reviewed two (2) staff files and three (3) resident files. Staff files were observed to be complete with required training. Residents files were current with necessary care plans and health documentation.

LPA requested the following documentation be sent to the Regional Office: LIC 500, LIC 308, LIC 610, and copy of Liability Insurance

Per California Code of Regulations (CCR) Title 22 - No deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
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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