342701006-7-19-2021-27-AS-CVAO-C53MMF-20210719094353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701006
Report Date: 07/19/2021
Date Signed: 07/19/2021 09:44:02 AM

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:	PERPETUAL MANOR		FACILITY NUMBER:	342701006
ADMINISTRATOR:	FERNANDEZ, ANGELICA		FACILITY TYPE:	740
ADDRESS:	9449 PINOT BLANC CT.		TELEPHONE:	(916) 430-6989
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 0	DATE:	07/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Angelica Fernandez		TIME COMPLETED:	10:00 AM

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	On 07/19/21 at 8:00AM, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to conduct an announced pre-licensing visit. LPA Valerio introduce herself and discussed the elements of the pre-licensing visit with Administrator Angelica Fernandez. The facility has a fire clearance for 6 residents. Bedrooms #1, #2, and #3 may only be occupied only by ambulatory residents. Bedrooms #4 and #5 may be occupied by a non-ambulatory or ambulatory residents Observed there are no residents at this time. The facility will have a Dementia Special Care Program. Angelica will be the designated Administrator for the facility, Administrator Certification Expiration 09/31/2021. The facility has an approved LIC 808 mitigation plan on file and uploaded into FAS. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. No concerns. The facility is a 5-bedroom, 3 bath home with 1 social room, living room, dining room, laundry room, kitchen, garage, and exterior area. The exterior area has a large space for visiting with a walk way for exercising. In the left corner of the backyard, there is a water pump that will be removed; however, it is not obstructing any walkways or a trip hazard. Residents will have access to all areas except the garage, medication area, and the locked cabinet storage for cleaning supplies and sharps. LPA observed the area where the staff and resident files will be locked and readily available for review. Emergency disaster plan and necessary signage posted and available at the front entrance. Facility has a 30-day supply of PPE located in the closet in the garage. First aid kits and emergency supply of food were observed to be fully stocked. LPA observed no obstruction of emergency exits inside or outside of facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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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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: PERPETUAL MANOR	FACILITY NUMBER: 342701006
	VISIT DATE: 07/19/2021

NARRATIVE

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Continued from LIC 809...

LPA’s observed the kitchen area, dining area, bedrooms, bathrooms, storage area, and office. Resident bedrooms observed to have necessary furniture. Resident bedrooms are furnished with a bed, chair, night stand, personal dresser, and extra closet space. Resident non-ambulatory rooms were observed to have exit ways. All exit ways have an accessible ramp. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. All bathrooms have ADA approved handrails, shower chairs, and a lifted toilet seat with handrails. All emergency exits are posted. Cleaning supplies were secured and locked in garage and laundry room. LPA observed smoke detectors and carbon monoxide detectors were noted and functioning properly. LPA Valerio and Administrator Angelica observed the hot water temperature in resident's bathrooms at 116.6*F, 108*F, and 109*F , within regulatory range of 105 *F and 120 *F. LPA observed area where food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.

LPA Valerio observed fire extinguisher in place outside of kitchen area and fully charged, last inspected on May 21, 2021.

Pre-Licensing is complete and this facility has no deficiencies. A Component III was completed at this time with the Applicant. Administrator Angelica had no further questions. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC809 (FAS) - (06/04)

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