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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700088
Report Date: 06/03/2022
Date Signed: 06/03/2022 11:02:26 AM


Document Has Been Signed on 06/03/2022 11:02 AM - 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:NJ CARE HOMEFACILITY NUMBER:
342700088
ADMINISTRATOR:JAMES, MERLITAFACILITY TYPE:
740
ADDRESS:8200 WOODED BROOK DRIVETELEPHONE:
(916) 248-0652
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Merlita James - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a required 1 year Required Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. Administrator Certificate expires 7/30/2022.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 108.5 F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed several freezers in the garage. Fire extinguishers expire 08/3022 and smoke detectors are current and in compliance with fire safety. LPA noted the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.
LPA reviewed 5 resident records and (3) staff records. LPA reviewed medications for 2 residents comparing with Centrally Stored Medication Record and physician orders. LPA observed that the facility is dispensing medications as prescribed. A review of (3) staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed.

LPA requested the following documents to be submitted to Community Care Licensing (CCL) by June 30, 2022: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate

Per California Code of Regulations, Title 22 no deficiencies were cited during today's inspection. An exit interview was conducted with Administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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