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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:24:48 AM


Document Has Been Signed on 08/04/2022 11:24 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:ORANGE GROVE SENIOR LIVINGFACILITY NUMBER:
342700151
ADMINISTRATOR:VENEGAS, MARICAR MERCADOFACILITY TYPE:
740
ADDRESS:228 GRACE AVENUETELEPHONE:
(916) 993-9099
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 5DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Theresa Autencio Christine TorresTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/04/2021. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The LPA toured the facility with Christine Torres on 08/24/2021 at 10:50 AM.

Administrator holds current certificate. The facility is licensed for six resident (three ambulatory and three non-ambulatory) There are currently 5 residents who reside at this facility.

The facility has one main entry screening point. The facility conducts disinfecting cleaning daily, and the facility has a 30 day supply of PPE. The facility has covid-19 postings throughout the facility. The facility furniture is spaced 6 feet apart. The facility was sanitary and clean. Smoke and Carbon detectors were in good repair. LPA Martinez reviewed one employee file and one resident file. The facility files were up to date. Moreover, resident bedrooms and bathrooms were sanitary. The facility has a seven day supply of food, and all toxins are locked.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


Exit interview held and a report given at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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