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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:01:37 PM

Document Has Been Signed on 04/11/2024 12:01 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:LEXIE RAE'S CARE HOMEFACILITY NUMBER:
342700507
ADMINISTRATOR/
DIRECTOR:
RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Annie Lyn RodriguezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 4/11/2024, at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA Villanueva initially met with the staff on duty and explained the purpose of the visit. The Administrator on record Annie Rodriguez was notified of the visit and arrived shortly after. Upon arrival to this facility, LPA observed 5 resident in care with 1 staff on duty.

At 10:46am, LPA Villanueva conducted a facility observation to ensure compliance with Title 22 regulations. LPA observed the stipulation order is posted in a conspicuous place located at the office area of the facility. During this visit, LPA observed a hospice personnel arrived to conduct a faith/religious session with the resident that was sitting in the living room. During the observation of the outside area, LPA observed the side gate located at the right side of the facility sketch has been repaired as advised during their annual visit. LPA observed both side gates to be working properly and both are self-latching. LPA observed the inside of the facility to be clean, safe, sanitary and in good repair. Medications, sharps, and toxic products were observed to be properly stored, kept in safe and locked place, and are inaccessible to residents in care. LPA observed required staff monthly training completed in March 2024 with the following topics: observation of change in condition of residents, duty to obtain timely medical care, prevention of pressure sore, prohibited conditions, stages of pressure injuries, and how to call 911. LPA reviewed three resident files and two staff files. LPA did not observe residents with prohibited health conditions during resident file review. Also during resident file review, LPA observed one resident with an incident report that was submitted to the Department. Staff working in the home were observed to be fingerprint cleared. Also staff that were reviewed have current first aid/CPR certificate.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Annie Lyn Rodriguez, and a copy of the report was provided
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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