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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700105
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:54:42 PM

Document Has Been Signed on 05/26/2023 03:54 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 AC/SC, 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: 3DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Naomi GuevarraTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Naomi Guevarra and explained the purpose of the visit. Three residents were present at the time of the visit, and the fourth was out at day program.

Guevarra's administrator certificate number is 6033012735 and it expires on 12/9/23.

LPA Moleski reviewed two resident files (R1-R2) and four staff files (S1-S4).

LPA Moleski toured the facility with Guevarra and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested and measured 119 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed a first aid kit, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked cabinet for the storage of cleaning solutions. LPA Moleski observed a locked cabinet for the storage of knives.

LPA Moleski interviewed two staff members (S5-S6) and one resident (R3).

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Mercado.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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