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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:40:05 AM


Document Has Been Signed on 08/10/2023 11:40 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Staff - Sevrena MillerTIME COMPLETED:
12:00 PM
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On 08/10/2023 Licensing Program Analysts (LPAs) Ivan Avila and Talwinder Bains arrived at the facility unannounced to conduct a 1-year annual inspection. Upon arrival LPA Bains called Administrator Nini Alfonso and explained the purpose of the visit. Administrator designated staff member Sevrena Miller to conduct the annual inspection and sign the final report.

Food: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPAs observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer inaccessible to residents in care. Bedrooms: The LPAs observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPAs observed the residents' bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. Water temperature in the residents’ restrooms was measured at 114.0 degrees Fahrenheit. Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. LPAs observed fire extinguishers (Serviced 03/24/2023), fire detectors, and carbon monoxide detectors. Record Review: A review of facility files was initiated. Facility records are stored inaccessible to residents. The LPAs reviewed two (2) staff, and two (2) resident files. All documents reviewed appeared complete and current. LPAs reviewed centrally stored log for two (2) residents and observed medications are given per residents' physician orders.

Several topics were discussed. Exit interview conducted and copy of the report provided to Sevrena Miller

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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