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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700896
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:06:31 PM

Document Has Been Signed on 06/27/2023 12:06 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MVP CAREHOMEFACILITY NUMBER:
342700896
ADMINISTRATOR:PURUGGANAN, EVELETH R.FACILITY TYPE:
735
ADDRESS:5914 WEDGEWOOD AVENUETELEPHONE:
(909) 384-2276
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Paz Yntela and Eveleth PuruggananTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Cassie Yang and Jaynae Boyles arrived unannounced at the facility to conduct a required annual inspection utilizing the full CARE tool. LPAs met with lead direct support professional (DSP), Paz Yntela, and explained the purpose of the visit. DSP then contacted Administrator (Admin), Eveleth Purugganan, who later arrived to the facility at approximately 9:30 AM.

LPAs were informed the facility has six (6) clients but currently three (3) are at adult day program. LPAs observed the presence of three (3) DSPs at the facility.

LPAs conducted a tour with DSP toured the interior and exterior of the facility to ensure the health and safety of clients in care. Areas toured included but not limited to: common areas, (1) staff room, (5) clients room, (2) bathroom, kitchen, laundry room, backyard and the storage/garage. LPAs observed a bedroom present in the garage, DSP clarified it was recently built and it will be for the night staff. In areas toured, no immediate health, safety or personal rights violation was observed.

LPAs observed facility to have 2+ days of perishables and 7+ days of nonperishables food. LPAs observed the temperature to be at 73* inside the facility. LPAs checked the hot water temperature to be at 110* in (2) bathrooms and kitchen sink. LPAs observed the fire extinguisher to last be serviced on 1/18/2023. LPAs observed Administrator Certificate #6045119735 to be current with expiration date of 9/13/2023. Admin informed LPAs renewal has been sent to CCLD. Additionally, LPAs requested a copy of LIC 500, LIC 308, Administrator Certificate to be emailed to LPA Yang by Friday July 7, 2023.

LPAs and Admin completed the full CARE tool together and found the facility to be in compliance. No deficiencies cited.

Exit interview conducted, and a copy of the report was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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