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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700407
Report Date: 11/07/2024
Date Signed: 11/07/2024 10:10:30 AM

Document Has Been Signed on 11/07/2024 10:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:A & R QUALITY CARE 2FACILITY NUMBER:
342700407
ADMINISTRATOR/
DIRECTOR:
HERNANDEZ, AMORFACILITY TYPE:
735
ADDRESS:5041 JURGENSON WAYTELEPHONE:
(916) 896-5588
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Rosalie LacarTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Designated Staff Rosalie Lacar, and explained the purpose of the visit.

LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed common areas to be fully furnished, clean, and free from debris. There were no odors throughout the home. Resident bedrooms were observed to be fully furnished, beds with quality and clean linens, and personalized to resident's preference. Resident bathrooms were stocked with hand soap, hand sanitizer, paper towels, toilet paper, and a trash can. Hot water was measured at 107.1 degrees F, which is within the required range of 105.0 - 120.0 degrees F. The facility kitchen was observed to have medications, sharps, and toxins locked an inaccessible to residents in care. The facility met the required food requirements. The backyard was observed to have a place to sit and have outdoor activities. No health or safety concerns were observed. The fire extinguisher, air conditioning/heating, carbon monoxide detectors were observed to be in working condition. Residents were observed to have left for Day Program.

LPA Valerio reviewed two (2) resident files and three (3) staff files. Resident files were observed to be complete with annual documentation. Staff files were observed to be up to date with required training.

LPA Valerio requested the following annual documentation: LIC 500, LIC 308, LIC 610, and copy of surety bond.

Per California Code of Regulations (CCR) Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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