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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700585
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:24:14 PM

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:INDOCARE HOUSE 2FACILITY NUMBER:
342700585
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8604 BANFF VISTA DRTELEPHONE:
(916) 686-1253
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Orpha ManalansanTIME COMPLETED:
03:30 PM
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On 09/22/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 2:40 PM, LPA met with the Main Caregiver Orpha Manalansan at the front door of the facility. LPA explained the purpose of the Infection Control visit. At approximately 2:50 PM, LPA Filouane conducted a tour of the facility with the Main Caregiver.

The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. At 2:55 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris. The facility's food supply was sufficient. PPE and cleaning supplies are stocked and sufficient.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer.

At approximately 2:55 PM, LPA completed the facility tour for Infection Control with the Main Caregiver. This report was reviewed with the Main Caregiver. No deficiencies were cited today.

Exit interview conducted with the Main Caregiver. A copy of this report will be emailed to the Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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