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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700544
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:55:39 PM

Document Has Been Signed on 04/09/2024 03:55 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:CISTERS LOVING CARE HOMEFACILITY NUMBER:
342700544
ADMINISTRATOR/
DIRECTOR:
CISTER, ROCHELLE HFACILITY TYPE:
735
ADDRESS:9837 LUCCA WAYTELEPHONE:
(916) 897-3098
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Rochelle CisterTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA Valerio was met by facility staff, and explained the purpose of the visit. LPA was later met by Administrator Rochelle Cister.
LPA Valerio inspected resident bedrooms, resident bathrooms, living room, kitchen area, storage areas, and backyard. Resident bedrooms were observed to be fully furnished, clean, and free from odors. Resident bathrooms were equipped with hand soap, hand sanitizer, paper towels, toilet paper and a trash can. Common areas were furnished and clean. The facility was observed to have a minimum of seven day non-perishable food items and a two day perishable food items. An emergency supply of food and water were observed. The medication cabinet, sharps, and toxins/chemicals were locked away and inaccessible to residents in care. The facility first aid kit was fully stocked. LPA observed fire alarms, carbon dioxide detector, and heating/air condition to be in working condition. The exterior area is a large area with areas to sit, areas to engage in outdoor activities, and for outdoor visitation. No emergency exits were obstructed. Fire extinguishers were observed to be within compliance with a last check on 06/19/2023. The last fire drill was conducted on 04/02/2024. Residents were observed arriving from Day Program, watching television, engaging in activities in their bedroom, playing outside, taking medication, and engaging with staff. Staff were observed assisting residents, providing assistance with afternoon snack, and assisting with daily activities. LPA interacted with staff and residents during the visit.
LPA Valerio reviewed 3 staff files and 2 resident files. Staff files were observed to be up to date with required annual training. Resident files were complete with required information.
LPA Valerio requested the following annual documentation be sent to the Regional Office: LIC 500, LIC 308, LIC 610, Surety Bond, and Copy of Administrator Certificate.

Per California Code of Regulations (CCR) - Title 22, no deficiencies observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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