<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:34:19 AM


Document Has Been Signed on 08/17/2022 10:34 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) 812-0944
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Janssen CarmonaTIME COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 8/17/22 at 9:15 am to conduct an annual inspection visit. LPA met with designated staff Janssen Carmona and explained the purpose of the visit.

Administrator holds current certification #6001838740 and expires on 4/24/2023. The facility is licensed for 4 non-ambulatory and 2 ambulatory residents. Approved hospice waiver for 6. There are currently 5 residents who reside at this facility.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 115.2 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 71 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA completed the infection control domain tool.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 WAY
FACILITY NUMBER: 342700587
VISIT DATE: 08/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility mitigation plan was submitted to CCLD, and it was approved on 4/28/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3