342700439-8-20-2021-27-AS-TTRG-C63TEJ-20210820144000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700439
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:40:07 PM

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:	CROWN MANOR		FACILITY NUMBER:	342700439
ADMINISTRATOR:	VILLANUEVA, ROWENA		FACILITY TYPE:	735
ADDRESS:	4624 CROWN BENCH CIR		TELEPHONE:	(916) 508-3910
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	4	CENSUS: 0	DATE:	08/20/2021
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator, Rowena Villanueva		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/20/2021 at 1:15 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA has attempted to conduct an annual inspection at this facility on 8/5/2021 but was advised by the administrator that she was unable to come and that there’s no at the facility. LPA was informed that the facility does not have any clients. LPA met with Administrator Rowena Villanueva and explained the purpose of today’s visit. Administrator holds current certification #6013029735 and expires on 10/4/2022. The facility is licensed to serve up to (4) four clients (3 ambulatory and 1 non-ambulatory). LPA toured the facility with Administrator Rowena Villanueva on 08/20/2021 at 1:30 pm. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms; client bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 119.8 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA observed the medication cabinet was locked. LPA also provided technical assistant regarding fit testing requirements. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CROWN MANOR	FACILITY NUMBER: 342700439
	VISIT DATE: 08/20/2021

NARRATIVE

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The facility mitigation plan was submitted to CCLD, and it was approved on 3/6/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview held with Administrator Rowena Villanueva and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC809 (FAS) - (06/04)

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