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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700717
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:30:14 PM

Document Has Been Signed on 01/18/2023 01:30 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:EVA LUIS RESIDENTIALFACILITY NUMBER:
342700717
ADMINISTRATOR:MANIQUIZ, LUISFACILITY TYPE:
735
ADDRESS:6845 CUNNINGHAM WAYTELEPHONE:
(916) 346-5602
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 4DATE:
01/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Luis ManiquizTIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPA) Pang Lee and Tung Truong arrived at the facility to conduct an unannounced annual inspection on 01/18/2023. LPAs met with administrator Luis Maniquiz and explained the purpose of the visit. Administrator Luis Maniquiz assisted with today’s visit. Administrator certificate #6049248735 will expire on 06/24/2024. Licensee Eva Maniqiz administrator certificate # 6049258738 will expire on 08/16/2024.There are four clients in care at this time.

LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (3) ambulatory residents of which one (1) non-ambulatory in bathroom with direct exit only. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPAs observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 115.9 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher is up to date. Facility thermostat observed at 69 degrees Fahrenheit. LPAs checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was checked and is complete. LPAs conducted the inspection tools.

LPAs observed toxins/chemicals cabinet was not locked and accessible to clients.


Report continued 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EVA LUIS RESIDENTIAL
FACILITY NUMBER: 342700717
VISIT DATE: 01/18/2023
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LPAs requested client and staff files for review. LPAs reviewed (2) client files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPAs verified staff training for staff file reviews.

Licensee was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)

Per California Code of Regulations, Title 22, deficiencies were observed and cited during this visit. Exit interview was conducted and a copy of this report, LIC 809-D, and appeal rights was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/18/2023 01:30 PM - It Cannot Be Edited


Created By: Pang Lee On 01/18/2023 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EVA LUIS RESIDENTIAL
FACILITY NUMBER: 342700717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings and Grounds
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above. Licensee did not ensure that chemicals were locked up. This poses an immediate health and safety risk to residents in care
POC Due Date: 01/19/2023
Plan of Correction
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 Licensee locked up the chemicals in an outside storage cabinet. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
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