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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700185
Report Date: 05/20/2025
Date Signed: 05/20/2025 04:03:44 PM

Document Has Been Signed on 05/20/2025 04:03 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:CUPINO HOMEFACILITY NUMBER:
342700185
ADMINISTRATOR/
DIRECTOR:		MONICA BUTAYFACILITY TYPE:
735
ADDRESS:8636 LILYPAD LANETELEPHONE:
9165099450
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:MONICA BUTAYTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 05/20/2025 unannounced annual inspection was made to this facility by Licensing Program Analysts (LPAs) Sommer Hayes and Arvin Villanueva. The LPAs identified themselves and the purpose of the visit and asked to speak to the Designated Facility Administrator. LPAs was met by Monica Butay the Facility Administrator and a brief interview followed.

LPAs observed the smoke detector and carbon monoxide detector. Both were tested and found in good repair. Fire extinguishers were in the hallway and in the kitchen were observed and in compliance. They were last serviced on 10/31/2024. Fire Extinguishers were serviced by River City Fire.

Kitchen 1:30pm
The kitchen was accessible to residents and clean and sanitary. The LPAs observed 7 days of non-perishable and 2 days of perishable food supplies. Freezer is 0 degrees F. Refrigerator is 40 degrees F. There is enough clean plates and cutlery to meet capacity. Opened packages in the refrigerator were dated appropriately. All pantry items were dated as well.

Garage 1:40pm
The garage was accessible to residents with supervision, clean and sanitary. The LPAs observed a hot water heater that was protected with a black gate and a self-latching lock. Garage contained three exercise equipment, a staff refrigerator, holiday decorations and table and chairs. There was a door leading to the backyard that was locked.

Continued on the LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CUPINO HOME
FACILITY NUMBER: 342700185
VISIT DATE: 05/20/2025
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Backyard: 1:55pm
LPAs observed the backyard of the facility to be clean and free of obstruction. There is a shaded area for residents to enjoy. There is an Additional Dwelling Unit (ADU) located in the back of the facility. LPAs observed one staff member who resides there. There was a small kitchenette, bathroom and bunk beds with a small living area near the front door. A small shed was observed by the LPAs which contained old staff files, cleaning supplies and gardening tools. There were no bodies of water. Two chairs were in disrepair. The Administrator stated that she will remove both chairs immediately. Administrator, Monica Butay stated the cameras mounted on the left side backside of the house were not in working order. A plank in the fence to the right of the house was in disrepair. Administrator, Monica stated she will repair it.

Living Room 2:10pm
LPAs observed the facility living room to be clean and free of obstruction. The temperature reading was 72 degrees Fahrenheit per Title 22 regulations. The seating is efficient seating for the number of residents in this facility. The fireplace is electric and is covered.


Hallway Bathrooms 2:40 PM
LPAs observed hallway bathrooms to be clean and in good repair. Water temperature was 114.6 degrees Fahrenheit in bathroom #1, within range of 105 to 120 degrees per Title 22 regulations. Bathroom contained required non-skid flooring, paper towels and grab bars.

Hallway Storage 2:50 PM. LPAs observed a hallway closet to be locked with extra linens, winter coats and cleaning supplies.

Bedrooms 3:00 PM
LPAs inspected all resident bedrooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. All bedrooms are single occupancy. There were clean linens, bedspreads and extra linens in the closets.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CUPINO HOME
FACILITY NUMBER: 342700185
VISIT DATE: 05/20/2025
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Centrally Stored Medication 3:15 PM
LPAs observed the centrally stored medication cabinet to be locked and inaccessible to residents. All residents’ medications are individually stored in clear boxes with their pictures. No medications were expired.

Staff/Resident Record Review 4:00 PM, LPAs conducted a file review of 2 client files and 3 staff files. All required documentation was found to be present and current. LPAs further observed the facility to be conducting fire drills monthly with the last drill being conducted on May 12, 2025. Two client cash records were reviewed. LPAs observed a first aid kit equipped with a first aid manual, tweezers, a thermometer and scissors.

Administrator, Monica Butay will submit an updated Infection Control Plan, Emergency Disaster Plan and a updated copy of the Liability Insurance.

According to the California Code of Regulations,Title 22, there were no deficiencies observed or cited during this visit.



A copy of this report was provided.

Exit interview.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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