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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700118
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:40:12 AM


Document Has Been Signed on 07/29/2022 11:40 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:A CARING HANDFACILITY NUMBER:
342700118
ADMINISTRATOR:JANKOWSKI, AMELITAFACILITY TYPE:
740
ADDRESS:6813 ELVORA WAYTELEPHONE:
(916) 685-3093
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Carestaff Marivic DaduyaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility unannounced to conduct an annual/required inspection visit. Upon arrival, LPA Lund met with caregiver Marivic Daduya and explained the reason for the visit. Caregiver Marivic Daduya called Administrator, Michael Jankowski who could not make the visit today and gave permission for Marivic Daduya to sign required paperwork. The facility is licensed to serve up to (6) six residents of which all can be non-ambulatory. Approved hospice waiver for (4) four. There are currently 6 residents who reside at this facility.

LPA Lund toured the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview held with caregiver Marivic Daduya and Administrator Michael Jankowski over the phone and a copy of report was left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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