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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700105
Report Date: 04/20/2022
Date Signed: 04/20/2022 02:55:33 PM

Document Has Been Signed on 04/20/2022 02:55 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:NAOMI GUEVARRA RESIDENTIALFACILITY NUMBER:
342700105
ADMINISTRATOR:GUEVARRA, NAOMIFACILITY TYPE:
735
ADDRESS:8186 LAGUNA BROOK WAYTELEPHONE:
(650) 580-8857
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 5CENSUS: 5DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Naomi Guevarra - Licensee/AdministratorTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit. LPA met with Licensee and stated the purpose of today’s visit. Facility is licensed to serve a total capacity of
5 residents.

LPA toured physical plant with Administrator inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed (2) residents resting in bedrooms and the other (3) residents are at day programs. LPA observed the facility conducts fire drills monthly and last drill was 4/4/2022. All required COVID-19 measures were observed. LPA observed staff and Licensee/Administrator wearing a mask. Staff took LPA temperature and a sign in sheet for visitors was at front door. Visitors are not allowed in the home due to COVID-19 pre-cautionary measures, but can visit residents in the backyard. LPA observed signs and postings. LPA observed outside fencing in good condition. LPA observed garage cleared out and extra freezer in corner. The thermostat temperature inside the facility hallway was measured at 73 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water measured at 107.2 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed a pull alarm system, fire extinguisher(s) expire 07/05/2022, smoke and carbon monoxide detectors in working order, and central heating and air in the facility. LPA observed cleaning supplies and toxins locked up in the kitchen and laundry room. LPA observed a washer and dryer ready in use. LPA observed the backyard with a locked shed.

Continue on 809-C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: NAOMI GUEVARRA RESIDENTIAL
FACILITY NUMBER: 342700105
VISIT DATE: 04/20/2022
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LPA observed there was not enough food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Storage and lighting was adequate in the home. All exit doors have sound alarms. LPA observed locked cabinet in kitchen where medications are inaccessible to residents in care.

LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).The first aid kit was found in compliance.

LPA reviewed (4) staff files. All staff is fingerprint cleared and associated to the facility and have current First Aid/CPR certifications on file. Facility conducts continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed (5) resident files which have all Community Care Licensing (CCL) documents.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, one deficiency was cited during this visit. If the deficiency is not corrected by the noted due date civil penalties may be assessed.

Exit interview held with administrator. A copy of reports were given to administrator and appeal rights..
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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Document Has Been Signed on 04/20/2022 02:55 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/20/2022 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NAOMI GUEVARRA RESIDENTIAL
FACILITY NUMBER: 342700105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in refrigerator did not have any eggs, cheese, milk, or fresh vegetables for fresh perishables for a minimum of two days. There also was not a staple of nonperishable foods for one week or variety of canned vegetables, only canned beans and rice. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee agrees to purchase eggs, cheese, milk, or fresh vegetables for fresh perishables for a minimum of two days. Staple of nonperishable foods for one week and a variety of canned vegetables were purchased during LPA inspection on 4/20/2022. LPA observed all groceries being put in refrigerator, pantry, and freezers. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


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