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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700533
Report Date: 09/06/2024
Date Signed: 09/06/2024 10:56:34 AM

Document Has Been Signed on 09/06/2024 10:56 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:COUNTRY ELEGANCE INCFACILITY NUMBER:
342700533
ADMINISTRATOR/
DIRECTOR:		BALLESTEROS, FLORENCIOFACILITY TYPE:
735
ADDRESS:9724 SPLENDER WAYTELEPHONE:
(916) 686-0611
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 4CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Florencio Ballesteros - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a required - 1 Year visit. LPA met with Administrator Florencio Ballesteros and explained the purpose of today’s visit.

Administrator certificate expired on 7/15/2024. Renewal application is pending. The facility is licensed for four (4) ambulatory client only. LPA observed 2 clients and 3 staff present during this visit. Administrator assisted LPA in today’s inspection.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to clients. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 108*F which is within the required range of 105-120*F. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. All emergency exits were clear from obstructions.

LPA requested client and staff files for review. LPA reviewed four (4) client files and three (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following forms and documents were requested to be submitted within 15 days:
LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, Administrator Certificate, Surety Bond, and LIC 610 Emergency Disaster Plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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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