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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700716
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:25:12 PM

Document Has Been Signed on 08/16/2023 03:25 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 AC/SC, 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:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Pamela MirandaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski met with Pamela Miranda and explained the purpose of this visit.

The incident report described an incident that occurred on June 24, 2023, wherein staff discovered what appeared to be bloody paper towels in the bathroom left by a resident (R1). LPA Moleski interviewed Miranda and reviewed R1's file, including medical visit documentation. Miranda said a subsequent ER visit and a primary care physician visit did not find any evidence of injury. Miranda said the resident has previously drawn on himself with markers, and she suspects this may have occurred again. Miranda said all orange and red markers have been removed from the facility.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Miranda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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