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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700677
Report Date: 02/21/2023
Date Signed: 02/21/2023 09:48:47 AM

Document Has Been Signed on 02/21/2023 09:48 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: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: 4DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Facility StaffTIME COMPLETED:
09:55 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) Christina Valerio arrived unannounced at the facility to conduct an annual inspection. LPA met with facility staff, and explained the purpose of the visit.

Facility Staff and LPA Valerio toured the physical plant to ensure compliance of Title 22 regulations. LPA observed the kitchen to have an emergency supply of food, a locked cabinet for sharps and cleaning supplies, a supply of perishable foods for seven days, and a supply of non-perishable food for a minimum of two days. Resident rooms were furnished with required furniture and were clean and free from debris. Resident bathrooms were fully stocked with necessary items, including soap, hand sanitizer, paper towels, and a trash can with a lid. The fire extinguisher was fully charged with last check on 12/2022. The facility was observed to have a 30-day supply of PPE and an emergency supply of food/water. Technical Assistance was provided for a bathroom sink. While LPA was checking the water temperature, the pipe burst and started to spill out water. Facility staff will inform administrator.

Residents were observed to be taking a nap, watching television, and a few in their room.

LPA requested the following: Administrator Certificate, LIC 308 - Designation of Administrator Responsibility, LIC 610-D, and LIC 500 Personnel Summary

Per the California Code of Regulations, Title 22, no deficiencies were observed or cited.  Exit interview held with facility staff, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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 1