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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700139
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:25:58 PM

Document Has Been Signed on 04/25/2024 03:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BASTONA MANORFACILITY NUMBER:
342700139
ADMINISTRATOR/
DIRECTOR:		VILLANUEVA, ROWENAFACILITY TYPE:
735
ADDRESS:1808 BASTONA DRIVETELEPHONE:
(916) 667-8721
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Christopher Benitez and Myla GaneTIME VISIT/
INSPECTION COMPLETED:
03:38 PM
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On 04/25/2024 at 145 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a collateral visit. LPA Lee met with direct care staff Myla Gane and Christopher Benitez and explained the purpose of the visit. LPA Lee spoke with facility administrator Rowena Villanueva over the phone and explained the purpose of the visit. Administrator stated that staff member could sign this report in her absence.

Upon arrival client 1 (C1) was not present in the home and was informed to LPA Lee by the care staff that (C1) usually comes back from day program around 2:30 PM. At approximately 2:50 PM (C1) arrived at the facility. LPA Lee conducted interviews with the administrator and with (C1). During today’s visit, LPA Lee requested the following copies to help with the investigation (C1):

· LIC 602 Physician Report

· IPP Individual Program Plan for 11/03/2023

· LIC 621 Client Personal Property and Valuables

· Windsor Elk Grove Care and Rehabilitation Order Summary Report

· Discharge Plan Documentation

· After Summary from Kaiser for 10/25/2023


No deficiencies were cited during this visit. An exit interview was held, and a copy of this report was left with Schumacher.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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