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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700716
Report Date: 01/04/2022
Date Signed: 01/04/2022 05:13:58 PM

Document Has Been Signed on 01/04/2022 05:13 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:MIRANDA GARDENSFACILITY NUMBER:
342700716
ADMINISTRATOR:MIRANDA, IANFACILITY TYPE:
735
ADDRESS:2405 RENWICK AVETELEPHONE:
(916) 955-1905
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Pamela Miranda TIME COMPLETED:
05:15 PM
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On 1-4-22 Licensing Program Analyst (LPA) Tirzah Hubbard arrived unannounced to conduct a Required – 1 Year inspection. LPA contacted the facility to ask follow up questions in regard to Covid-19. LPA spoke with the Licensee and Manager Pamela Miranda to ask follow up questions for Covid-19 symptoms. LPA proceeded to approach the facility to conduct the Annual after the facility was cleared. All required COVID measures were observed. LPA observed S1 and Administrator wearing mask upon entry. S1 took the temperature of LPA and asked Covid-19 screening questions. LPA Hubbard were allowed entry into the facility that is licensed to serve a total capacity of 4 clients. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents.

All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. All bedrooms contained a dresser, bed, and night stand. The flooring of the facility is a good condition. LPA observed the thermostat temperature inside the facility hallway was measured at 76 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 105 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).

All 4 staff are fully vaccinated. Staff will be eligible for June, 2022 Booster vaccination.
All 3 Residents are fully vaccinated. Residents are scheduled for booster for the month of January, 2022.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MIRANDA GARDENS
FACILITY NUMBER: 342700716
VISIT DATE: 01/04/2022
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The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

LPA observed the backyard area in good condition. The facility was clean and organized.


Upon a file review the following items were discussed to be submitted with any changes annually:

Criminal Record Clearances LIC508
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview held and a copy of report was provided in email for signature from licensee and copies faxed and emailed back.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
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