<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700949
Report Date: 02/18/2022
Date Signed: 02/22/2022 02:19:35 PM

Document Has Been Signed on 02/22/2022 02:19 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:FIELDALE FACILITYFACILITY NUMBER:
342700949
ADMINISTRATOR:HUFF, MARCUSFACILITY TYPE:
735
ADDRESS:6261 FIELDALE DRIVETELEPHONE:
(323) 459-8068
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Autumn HuffTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Unannounced annual visit made out to this facility on 02/18/2022 by LPA Charlie Yang and Passion Thomas who were met by the designated facility Administrator Autumn Huff. This LPA requested that she go ahead and call the facility Licensee, Marcus Huff, to inform him that CCL was present at this time.
This facility is licensed to accept and retain up to (4) ambulatory only residents at any given time. This facility is vendorized to accept and retain Level 4I residents through Alta Regional Center.
Current census was 4 residents.
Tour of the facility was conducted.
Kitchen area was toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. Drawers and cabinets were reviewed for adequate supplies.
Medication cabinet, located in hallway closet, was observed to be locked and made inaccessible to the residents at this time. A review was conducted with the resident medications and facility medication administration record.
First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguisher, located in kitchen area, was present and observed to have been annually purchased within the last calendar year and in compliance at this time.
Dining area, living area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident bedrooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet was reviewed. Linens, towels, and all items intended for resident use were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: FIELDALE FACILITY
FACILITY NUMBER: 342700949
VISIT DATE: 02/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Laundry area was toured. Detergents, bleach, and all cleaning agents were observed to locked in overhead cabinets and made inaccessible to the residents at this time.
Garage area was toured. Garage door was locked and made inaccessible to the residents at this time. Additional cleaning supplies and decorations for this facility were observed to be present and in good repair.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

The following forms were requested to be updated and submitted into CCL upon completion:

LIC 308
LIC 400
LIC 500
LIC 610

There weren't any deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2