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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700630
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:22:41 PM

Document Has Been Signed on 08/06/2024 04:22 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:L.P. NUNEZ CARE FACILITY #3FACILITY NUMBER:
342700630
ADMINISTRATOR/
DIRECTOR:		NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:8528 BIRCH CREST CTTELEPHONE:
(916) 647-9670
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Lionel NunezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 8/6/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their required annual inspection. LPA initially met with on of the staff on duty and stated the purpose of the visit. The administrator, Lionel Nunez, was notified of the visit and arrived shortly after. Present during today's visit were 3 residents in care with 2 staff on duty.

LPA and Administrator toured the facility physical plant to ensure compliance with Title 22 regulations. The facility is a one-story home located in a residential neighborhood. LPA observed the front yard to be clean and free of obstruction. LPA observed the backyard to have outdoor furniture and covered patio for outdoor activities. Fence and gate were observed to be in good repair.

LPA observed the 4 bedrooms to be furnished. 4 of 4 bedrooms are single/private room. Bathroom was observed to be fully stocked with toilet paper, paper towels, soap, trash can, and non-skid mats. Common areas were observed to be clean and free from debris. LPA observed the temperature inside the facility was measured at 73*F and the hot water was measured at 112*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area, toxins, and sharps to be locked and inaccessible to clients. LPA observed fire extinguisher with last serviced on 07/30/24, smoke and carbon monoxide detectors, central heating and air in the facility to be in good working condition. Fireplace was observed to be screened and has not been utilized as per Administrator.

LPA reviewed 4 of 4 resident files. 4 of 4 residents reviewed have completed records. LPA reviewed 2 of 4 resident medications and found to be in compliant. Facility handles resident money. 2 of 4 residents' P&I money were counted by Administrator while LPA observed and found to be accurate.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: L.P. NUNEZ CARE FACILITY #3
FACILITY NUMBER: 342700630
VISIT DATE: 08/06/2024
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LPA reviewed 4 staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. 4 of 4 staff reviewed have current 1st Aid/CPR certificates. 4 of 4 staff reviewed have Direct Support Professional (DSP) training certificates. Administrator certificate for Lionel Nunez is current.

Facility conducts drills on a monthly basis and last drill was conducted 8/3/24.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed or cited.

Administrator needed to leave during this visit and gave permission to Avery Mata, staff on duty, permission to sign this report.

An exit interview was held with Avery Mata and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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