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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701006
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:14:27 PM

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 MANORFACILITY NUMBER:
342701006
ADMINISTRATOR:FERNANDEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:9449 PINOT BLANC CT.TELEPHONE:
(916) 509-9668
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 3DATE:
11/10/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Angelica FernandezTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a post-licensing visit. LPA was screened for COVID-19 symptoms with temperature taken prior to being allowed entry into the facility. Administrator confirmed residents and staff have not displayed any signs or symptoms of COVID-19.

LPA Valerio toured the facility client bedrooms, bathrooms, hallway, kitchen, family room and dining area. All areas were clean and organized. Medication, knives, and toxins were all secured in cupboards and cabinets and inaccessible to clients.

LPA Valerio reviewed staff training records, resident medication administration records, resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.

LPA observed the facility to have a first aid kit, hand washing signage, and COVID-19 informational signage posted at the front door and throughout the facility. The facility is able to dedicate a COVID-19 bathroom and bedroom if needed. No health and safety concerns observed during the visits.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited.  Exit interview held with Administrator Angelica Fernandez and copy of report was left at the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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