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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:03:49 PM

Document Has Been Signed on 03/08/2022 03:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LEXIE RAE'S CARE HOMEFACILITY NUMBER:
342700507
ADMINISTRATOR:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
03/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence
an announced Office visit on 3/8/22 at 1:00pm. This meeting will be held using “Microsoft Teams”. Present in the meeting were Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephenie Doub, LPA Victoria Brown, LPA Christina Valerio, LPA Jamie Ivey Canady, representatives of 5M Care LLC and Mariolyn Care LLC: Annie Lyn J Rodriguez, and Monalisa Legaspi.

Krystall Moore discussed the purpose and elements of this type of call. It is to review the stipulation adopted on 2/22/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period of 3 years.

The Stipulation was reviewed with representatives of 5M Care LLC who expressed their understanding.

Items discussed at the meeting included, but not limited to:
Stipulation And Waiver; And Order
· Findings
· Revocations/Denial/Exclusion: STAYED with Probation
· Future Application for License, Registration, Certification or Approval
· Licensure Certification or Approval
· Trustline and Home Care Aide Registries
· Application Denial
· Tolling of Probationary Period
· Completion of Probation
Violation of Stipulation Term
· Department's Authority
· Monitoring Fee
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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: LEXIE RAE'S CARE HOME
FACILITY NUMBER: 342700507
VISIT DATE: 03/08/2022
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· Waiver of Hearing Rights;
· Waiver of Appeal/Modification Rights
· Waiver of Claims
· Severable Terms
· Public Record
· Signatures
· Counterparts
· Effective Date: (2/22/2022 – 2/22/2025)
· No Oral Modification
· Representations Re: Administrator presence

The Licensees/Respondents/Representatives stated they would abide by the following:
· Abide by the contents/terms of the Stipulation
· Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly
· Hospice Waivers: Service to only those currently residing in the home(s)

CCLD will do the following:
· Increase monitoring
· Contact the Administrator Certificate Unit regarding the issuance of a certificate to Annie Lyn Rodriguez due to the stipulation agreement

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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