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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 08/23/2023
Date Signed: 08/23/2023 10:56:43 AM


Document Has Been Signed on 08/23/2023 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 6DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janssen Carmona - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection. LPA met with administrator and explained purpose of visit. Administrator's Certification expires 08/192024. There are currently six residents who reside at this facility.

LPA and administrator inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. Food supply is adequate for two day perishable and seven day nonperishable. Fire extinguishers were last inspected on May 15, 2023. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. All Fire Exits are free of obstacles and last fire drill was completed on July 16, 2023.

LPA reviewed two staff and three resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

LPA requested the following updated documents for master file to be emailed by August 30, 2023:
Designation of Facility Responsibility (LIC 308), Personnel Report (LIC 500), Emergency Disaster Plan (610E), Liability Insurance, and Administrator Certificate.
ruth.wallace@dss.ca.gov

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

Exit interview conducted with administrator. LIC 811(Confidential Names) and copy of report left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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