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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700677
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:36:03 PM

Document Has Been Signed on 08/24/2021 04:36 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MISSION HOME CBN INCFACILITY NUMBER:
342700677
ADMINISTRATOR:CENTENO, CRISELDAFACILITY TYPE:
735
ADDRESS:8591 MISSION FALLS CIRCLETELEPHONE:
(916) 519-7474
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Orlando CarpioTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, explained the purpose of the visit, and was met by facility staff Orlando Carpio. LPA Valerio was screened for COVID-19 prior to being allowed entry. Staff confirmed no residents or staff have experienced any signs or symptoms related to COVID-19 in the last 10 days.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan uploaded into FAS. LPA Valerio reviewed and approved the plan with staff Orlando during the visit. LPA observed the facility to have COVID-19 informational signs, social distancing signs, hand washing signs posted throughout the facility. The facility is able to designated and dedicated a Covid-19 bedroom, bathroom, and isolation area if needed. The facility has a 30-day supply of PPE located in the garage storage area.
 
LPA observed the temperature inside the facility was measured at 74*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 107.3*F, within the regulatory range of 105 - 120 degrees 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, cleaning supplies, and sharps to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 12/20/2020. All emergency exits were clear from obstructions.
LPA requested updated copies of documentation: LIC 610D Emergency Disaster Plan

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left for Administrator Criselda Centeno.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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