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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700742
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:49:34 PM

Document Has Been Signed on 03/09/2022 03:49 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:RODNICK CAREFACILITY NUMBER:
342700742
ADMINISTRATOR:HAMMETT, REBECCAFACILITY TYPE:
735
ADDRESS:9060 LORDSHIP WAYTELEPHONE:
(916) 316-6213
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Facility StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey Canady arrived at the facility unannounced to complete an annual inspection. LPAs were met by facility staff, which confirmed no residents or staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPAs toured the physical plant inside and out to ensure compliance with Title 22 regulations. LPAs observed the common areas to be clean and free of debris. Resident rooms were furnished with required furniture and furnishings. Resident rooms were decorated according to resident's interests. Resident restrooms were clean and observed to have necessary hygiene products. Hot water was measured at 106.1*F, which is within the required range of 105*F - 120*F. LPAs observed the facility to have nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Food items were labeled and dated with the expiration date. Sharps, cleaning supplies, and medications were observed to be locked an inaccessible to residents in care. The facility has a pull-alarm system and fire extinguishers that were fully charge with last check on 07/23/21.

LPAs interacted with multiple staff and residents during the visit. Residents were observed to be engaged in activities such as card games, arts and crafts, listening to music, and playing on the computer. LPAs conducted the infection control domain tool. LPAs observed staff checking in and out on their COVID log.

LPA requested documents to be sent to LPA Valerio via fax: LIC 500 Personnel Report, LIC 308 Designation of Responsibility, and current LIC 610D,

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with facility staff, and a copy of the report was left for Administrator Rebecca Hammett.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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