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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700949
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:31:43 PM

Document Has Been Signed on 02/23/2023 03:31 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:FIELDALE FACILITYFACILITY NUMBER:
342700949
ADMINISTRATOR:HUFF, MARCUSFACILITY TYPE:
735
ADDRESS:6261 FIELDALE DRIVETELEPHONE:
(323) 459-8068
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Michael OlivaTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund made an unannounced annual/required visit to this facility on February 23, 2023. LPAs were met by staff, who contacted the house manager, Michael Oliva. When Oliva arrived, LPAs explained the purpose of the visit.

Current census was three residents, two of whom were out.

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.

During a facility tour, LPAs inspected the kitchen area and the food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities. Drawers and cabinets were reviewed for adequate supplies.

A medication cabinet, located in a hallway closet, was observed to be locked and made inaccessible to the residents at this time.

First aid kit was observed to be present and contained all of the required components 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 sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: FIELDALE FACILITY
FACILITY NUMBER: 342700949
VISIT DATE: 02/23/2023
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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. Furniture and furnishings appeared sufficient to meet the needs of the resident. Sinks in bathrooms were observed to have signs posted above warning that water temperatures exceed 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.

No deficiencies were cited. LPAs conducted an exit interview with Oliva.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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