342700507-2-4-2025-27-AS-AVIA-DDKRD4-20250204115518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:55:27 AM

Document Has Been Signed on 02/04/2025 11:55 AM - 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 HOME		FACILITY NUMBER:	342700507
ADMINISTRATOR/ DIRECTOR:	RODRIGUEZ, ANNIE LYN		FACILITY TYPE:	740
ADDRESS:	8818 SHARKEY AVE		TELEPHONE:	(916) 714-0853
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/04/2025
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Marvin Juan Rodriguez and Monalisa Salipan		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 2/4/2025, at 9:55pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to 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 designated staff, Marvin Juan (S1) Rodriguez and stated the purpose of this visit. The facility administrator, Annie Lyn Rodriguez is currently out of the country. The designated administrator Monalisa Salipan (AD) was notified and arrived shortly after. Present in today's visit were 4 residents in care with 1 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident. LPA conducted a physical inspection of the facility. Room temperature was measured at 74F and hot water temperature was measured at 118F in one of the bathrooms. 2 of 4 bedrooms were inspected and were observed to be clean and good repair. 1 of 2 bathrooms was inspected and was observed to be maintained and in good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Kitchen was observed to be clean at this time. Stipulation was observed in a conspicuous place at the office desk area. Since last visit on 10/15/24, there was one new admission. LPA reviewed resident's files. Resident records reviewed have medical assessment with TB test, admission agreement, preplacement assessment and hospice care plan. Technical advisory for staff to complete needs and services plan. Per review of the hospice care plan, R1 was diagnosed with a health condition (H1). Per interview with AD and S1, the H1 is not a result from a pressure injury but from a medical condition (M2). During this visit, LPA obtained relevant records for R1 for further review. Per stipulation, facility conducts monthly staff training. Last training was conducted on 1/5/25. {Con't to LIC809-C}

Stephen Richardson	TELEPHONE: (916) 263-4700
Arvin Villanueva	TELEPHONE: 916-208-0023
	DATE: 02/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEXIE RAE'S CARE HOME	FACILITY NUMBER: 342700507
	VISIT DATE: 02/04/2025

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Also during this visit, LPA followed-up on an incident that occurred on 1/28/25 were a resident in care (R1) was found on the floor by staff at around 6:03pm. Per incident report, staff on duty heard a loud sound and found R1 on the floor. R1's hospice nurse was notified and instructed staff to call 911. R1 was taken to the emergency. R1 returned to the facility the same day with stiches on the eyebrow area and was prescribed antibiotic for 7 days. Per review of R1's hospice binder, hospice nurse visited R1 the next day at the facility and R1 denies any pain. Per review of the discharge documents, R1 sustained facial injuries including skin tears and nose fracture. Per interview with S1 who was the staff on duty during the incident, S1 was at the kitchen cooking. S1 also indicated that R1 is not a fall risk and that R1 was confused at that time due to a suspected medical condition (M1) which was confirmed and was prescribed antibiotic. S1 added that after receiving antibiotic, R1 was mentally back to normal.

At this time, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC809 (FAS) - (06/04)

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