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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700053
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:10:00 PM

Document Has Been Signed on 11/07/2024 12:10 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:FILLON HOMEFACILITY NUMBER:
342700053
ADMINISTRATOR/
DIRECTOR:
FILLON, BETTY JEANNEFACILITY TYPE:
735
ADDRESS:10351 FRANK GREG WAYTELEPHONE:
(916) 478-4074
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH: Betty Jeanne FillonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio contacted Administrator Betty Jeanne Fillon via cell phone and explained the purpose of the visit. LPA was later met by Administrator Jeanne at the facility.

LPA Valerio toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed resident bedrooms to be fully furnished, clean, free from odors, and personalized to resident preferences. Resident bathrooms were observed to be fully stocked with hygiene supplies, paper towels, toilet paper, skid matt, hand rails, and a trash can. The kitchen and common areas were observed to be sanitary and clean. The facility met food supply requirements. No emergency exits were observed to be obstructed. LPA Valerio observed the backyard to have an area out outdoor activities or visits. No emergency exits were observed to be obstructed. The fire extinguisher was observed to be within compliance, fully charged, and had their annual maintenance check. The last fire drill was conducted on 10/07/2024.

Residents were observed to be gone for the day. Day staff left at 10:30 AM and afternoon staff will arrive when residents come back for their Day Program.

LPA Valerio reviewed two (2) resident files and two (2) staff files. Resident files were observed to be up to date with required documentation. Staff files were observed to have required training.

LPA reviewed annual documentation to be complete and up to date. LPA requested the following electronic copies be sent to LPA Valerio via email: LIC 500, LIC 610, LIC 308, Surety Bond, and 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 report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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