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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700716
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:01:39 PM

Document Has Been Signed on 01/06/2023 03:01 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: 4DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Pamela Miranda - House ManagerTIME COMPLETED:
01:30 PM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection. LPA's temperature was taken and asked COVID-19 screening questions. LPA was allowed entry into the facility that is licensed to serve a total capacity of 4 clients.

LPA and house manager toured the physical plant was toured inside and outside to ensure the safety of the residents. All required furniture was observed. LPA observed the facility conducts fire drills monthly on the 21st. The hot water was measured at 116.4*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. The first aid kit was in compliance. LPA observed a pull alarm system, fire extinguisher(s) were inspected on 12/22/2022, smoke and carbon monoxide detectors, central heating and air are present in the facility.

LPA observed 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.
The facility was clean and organized. LPA reviewed three (3) staff records and two (2) client records. All files were complete. Staff are fingerprint cleared and first aid certified. LPA observed the medication and the MARS sheets. Medications appear to be documented appropriately.

LPA received the following documents on 1/6/2023:
Administrative Organization LIC-309, Designation of Administrative Responsibility LIC-308
Personnel Report LIC-500, Emergency Disaster Plan LIC-610-D, Surety Bond, Administrator Certificate, and Lease Agreement

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview held with house manager and a copy of report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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