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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700139
Report Date: 09/17/2022
Date Signed: 09/17/2022 08:50:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/17/2022 08:50 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:BASTONA MANORFACILITY NUMBER:
342700139
ADMINISTRATOR:VILLANUEVA, ROWENAFACILITY TYPE:
735
ADDRESS:1808 BASTONA DRIVETELEPHONE:
(916) 667-8721
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
09/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Felicitas CabilesTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Felicitas and explained the purpose of the visit. Administrator was contacted and was unavailable for this inspection. The Administrator's certificate expired on 10/4/2022. The survey was later joined by Marilyn Schumacher and Myla Brown.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire drill was conducted on 9/7/22.

Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 6 resident and 5 staff files, including criminal record clearances.

All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility.

No Deficiencies were cited. Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2022
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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