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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700177
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:07:39 PM

Document Has Been Signed on 07/11/2022 12:07 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:EXCEPTIONAL SENIOR HOMEFACILITY NUMBER:
342700177
ADMINISTRATOR:PINLAC, MARIA ANA VFACILITY TYPE:
740
ADDRESS:9413 CORLEY COVE LANETELEPHONE:
(916) 941-5664
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cedric Pinlac, HousesitterTIME COMPLETED:
12:00 PM
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On 7-11-2022 at 9:15 AM, Licensing Program Analyst (LPA) Renee Campbell arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator's house sitter and explained the purpose of the visit. Administrator spoke with Administrator via phone as she was not present. Administrator stated they are not accepting no residents at the facility and that there were no plans to surrender their license at this time. LPA verified no residents are currently at the facility.

LPA Campbell inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 0.

Water temperature reads 120*F in the bathroom and room temperature reads 88*F. The facility common areas were furnished. Smoke and carbon detectors were in good repair.

Per California Code of Regulations, Title 22, no deficiencies were reported during this visit. Exit interview was held with Cedric Pinlac and a report was left at facility for Maria and emailed to her. Follow up may be required with visit in two weeks.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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