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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:31:08 PM


Document Has Been Signed on 08/08/2024 04:31 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:SIGNATURE LIVING ON LAVELLI WAYFACILITY NUMBER:
342700587
ADMINISTRATOR:ENERO, EDGARFACILITY TYPE:
740
ADDRESS:10125 LAVELLI WAYTELEPHONE:
(916) 896-0719
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Janssen Germono TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with facility staff, and explained the purpose of the visit. LPA Valerio was later met by designated administrator staff Janssen Germono.

LPA Valerio and co-administrator Janssen Germono toured the facility to ensure compliance with Title 22. Resident bedrooms were observed to be clean, free from debris, and fully furnished. Resident bathrooms were clean. Water faucets delivered hot water a temperature of 105.9 degrees F, which is within the required range of 105-120.0 degrees F. The facility common areas were clean, fully furnished, and free from odors. Emergency exits were clear from obstructions. The fire extinguisher was observed to be fully charged with a last inspection of May 14, 2024. Carbon monoxide, fire detectors, and air conditioning was observed to be in working condition. The temperature inside the home was 73 degrees. The kitchen was observed to be clean. The facility was observed to have an adequate food supply and an emergency supply of food.

Residents were observed watching television, eating a snack, and out on an outing. Staff was observed cleaning, preparing for dinner, and assisting with resident request.

LPA Valerio reviewed two (2) staff files and two (2) resident files. Staff files were observed to be complete with required training. Resident files were observed to be current with required annual documents.

LPA requested the following annual documentation: LIC 500, LIC 308, LIC 610E, and copy of liability insurance.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held with Co-Administrator Janssen, 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: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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