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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700439
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:30:33 PM

Document Has Been Signed on 02/25/2025 03:30 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/
DIRECTOR:		VILLANUEVA, ROWENAFACILITY TYPE:
735
ADDRESS:4624 CROWN BENCH CIRTELEPHONE:
(916) 897-8584
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Rowena VillanuevaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 2/25/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their annual inspection visit. Initially, no one was present at the facility. LPA contacted the administrator, Rowena Villanueva, who informed LPA that residents in care are currently out in the community and staff should be arriving in couple of minutes. Staff on duty arrived at 2pm and LPA stated the purpose of this visit. Administrator arrived shortly after.

LPA and staff toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. This facility is a one-story home located in a residential neighborhood. LPA observed fence and gates were in good repair at this time. LPA observed outdoor furniture and covered area for outdoor activities.

LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The temperature inside the facility was observed to be at 74 degrees Fahrenheit. The hot water temperature was measured at 111 degree Fahrenheit. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

During this visit, staff tested one of the smoke detectors and carbon monoxide dectector and were found to be operable at this time. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.


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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 3
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: CROWN MANOR
FACILITY NUMBER: 342700439
VISIT DATE: 02/25/2025
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LPA reviewed 4 staff files. 4 of 4 staff were found to have current 1st aid/CPR certificate, health screen and have background clearance and are associated to this facility. LPA reviewed 3 resident files. 3 of 3 residents have medical assessments and current Individual Program Plan. LPA reviewed 3 resident cash and found to be accurate at this time. LPA conducted medication review of 2 residents. Facility conducts monthly fire drills.

Copy of the following documents were requested during this visit:
Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Surety Bond, and Liability Insurance Certificate.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report was provided.


















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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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