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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700439
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:08:24 PM

Document Has Been Signed on 04/04/2024 02:08 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:CROWN MANORFACILITY NUMBER:
342700439
ADMINISTRATOR:VILLANUEVA, ROWENAFACILITY TYPE:
735
ADDRESS:4624 CROWN BENCH CIRTELEPHONE:
(916) 897-8584
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 3DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Veronica RojasTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA Valerio was met by facility staff Veronica Rojas, and explained the purpose of the visit. LPA spoke to Administrator Rowena, which appointed designated staff, Amor, to assist LPA with the visit.

LPA Valerio and facility staff Veronica toured the facility to ensure compliance of Title 22 regulations. LPA toured resident bedrooms, bathrooms, common areas, exterior area, garage, and the kitchen area. No health or safety concerns observed. Resident bedrooms were clean and free from debris. Resident bathrooms were fully stocked with toilet paper, paper towels, hygiene supplies, soap, hand sanitizer, and a trash can. No foul odors were observed. Hot water was measured between regulatory range of 105-120.0*degrees. The temperature inside the home was 70*degrees. Medications, cleaning supplies, and sharps were observed to be locked away and inaccessible to residents in care. LPA observed the fire extinguisher to be in working condition. No emergency exits were obstructed. The facility was equipped with a food supply to meet the requirements of 2 day perishable items and 7 day non-perishable items. During the visit, there was one resident present while the other two were at Day Program. Staff and resident were observed to be doing activities together and separately.

Facility staff Veronica provided LPA 3 resident files and 2 staff files. All files were observed to be up to date with current information. LPA spoke to staff and resident 1(R1) during the visit.

LPA requested the following documents to be sent for the Regional Office facility file: LIC 500, LIC 308, LIC 610, Surety Bond, and Administrator Certificate

Per California Code of Regulation (CCR) - Title 22, no deficiencies were observed during today's visit. An exit interview was held with designated staff, Amor Hernandez, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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