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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700185
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:32:23 PM

Document Has Been Signed on 04/05/2022 04:32 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:CUPINO HOMEFACILITY NUMBER:
342700185
ADMINISTRATOR:CUPINO, RAULFACILITY TYPE:
735
ADDRESS:8636 LILYPAD LANETELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Monica Butay, AdministratorTIME COMPLETED:
03:40 PM
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On 04/05/2022 at 12:55 pm, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with Licensee, Raul Cupino and Administrator, Monica Butay. LPAs explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 4 ambulatory clients, which 2 maybe non-ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. Hot water temperature in client's shared bathroom was measured at 115.3 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

LPAs observed smoke detectors and carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on 10/12/2021. First aid kit observed to be complete. LPAs observed completed Mitigation Plan. Fire drill was last conducted on 03/14/2022. LPAs reviewed 4 client files and 3 staff records.

The following forms to be updated and submitted to CCLD by 04/15/2022:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610 Emergency Disaster Plan
No deficiencies cited during inspection. Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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