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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:40:38 AM


Document Has Been Signed on 06/06/2023 11:40 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
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: 5DATE:
06/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Annie RodriguezTIME COMPLETED:
11:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly case management visit. LPA Valerio met with Administrator Annie Rodriguez, and explained the purpose of the visit.

LPA observed the current stipulation order place in a conspicuous place in the front area of the home near the office desk.

LPA confirmed that the licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. All staff working in the home were observed to be fingerprint cleared. Staff have updated 2023 training that align with the stipulation order.

LPA observed 5 residents. Staff were playing guitar for the residents while 3 other residents were watching television and 1 was napping. LPA observed staff interactions with residents to be supportive, encouraging, and helpful. Staff was observed assisting resident with ADLs, providing refreshments, and engaging in conversations with residents in care.

The home was observed to be clean, organized, and free from obstructions. Alarms on doors were operating and alarmed when doors opened. An emergency supply of food was also observed.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Administrator Annie, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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