<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:17:13 PM


Document Has Been Signed on 07/24/2024 03:17 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:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
03:30 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 7/24/24, at 10:09am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license. LPA met with the facility administrator, Annie Lyn Rodriguez and stated the purpose of the visit. Present in today's visit were 3 residents in care with 1 staff on duty.

At 2pm, LPA conducted a physical inspection of the facility. Facility is located in a residential neighborhood and is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident. LPA observed front and back yard to be maintained and free of obstruction. Fences and gates were observed to be in good repair. Bedrooms and bathroom were observed to be clean and in good repair. Kitchen was observed to be clean and sanitary. Medications, sharp objects and toxins were observed to be locked and inaccessible to residents in care. Refrigerator and freezer temperature were measured within regulatory standard. Room temperature was measured at 74*F. Hot water temperature was measured at 110*F during this visit.

LPA conducted review of 3 staff records and 3 resident records. 3 of 3 staff records have current 1st aid/CPR certificates. 1 of 3 staff reviewed was a newly hired and have current health screen and fingerprint cleared. Discussion and advisory with the administrator was conducted to update 3 of 3 residents' Needs and Services Plan. Medication review was conducted for 2 of 3 residents and were observed to be in compliance.



{page 1 of 2}
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 2


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: LEXIE RAE'S CARE HOME
FACILITY NUMBER: 342700507
VISIT DATE: 07/24/2024
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
26
27
28
29
30
31
32
Per review of the stipulation order:
  • Current Respondents operate in strict compliance with the regulations and statues governing RCFE: Facility was observed to be in compliance during this visit.
  • Is there full compliance with the regulations and statues governing RCFE: Facility was observed to be in compliance during this visit.
  • Stay of exclusion is valid only for the conduct identified in the second amended accusation and second amended statement of issues: Facility was observed to be in compliance during this visit.
  • Stay of exclusion is valid for respondent Annie Lyn Rodriguez association to facility 1 & 2: Facility was observed to be in compliance during this visit.
  • Respondent completed 18 hrs. of training after 90 days of the Stipulation: Annie Lyn has completed 18 of 18 hours of training.
  • Stipulation is posted in a conspicuous place: Stipulation order was observed to be posted at the office area near the entrance.
  • Has there been incidents to report recently: Recent incidents has occurred and report to be submitted and still within reporting requirements: Advisory was provided to Annie Lyn to ensure verbal reporting of incidents need to be done within the next day of the incident either via phone or email.
  • Respondent cannot retain residents who have prohibited conditions: Annie Lyn has not retained nor accepted residents with prohibited conditions at this time.
  • Within 30 days of this stipulation, respondent have a written plan for obtaining timely medical care for residents? Have training of all staff on procedures: Per review of previous visits, Annie Lyn has submitted a written plan.
  • Within 30 days of this stipulation, respondent have plan in place to for extended absences of the administrator on record? Have training for staff on procedures: Per review of previous visits, Annie Lyn has submitted a written plan.
  • Monthly training of staff provided: Per document review, monthly training was being conducted. Last monthly training was conducted on 6/20/24.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was conducted with Annie Lyn Rodriguez, Administrator, and a copy of this report was provided.

{page 2 of 2}
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2