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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701006
Report Date: 08/05/2022
Date Signed: 08/05/2022 10:59:06 AM


Document Has Been Signed on 08/05/2022 10:59 AM - 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: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: 4DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Angelica Fernandez - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA's) Ruth Wallace Kesha Lewis arrived to conduct unannounced Required 1 Year Annual Inspection Visit. LPA's 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's and Administrator toured the facility resident 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. The hot water was measured at 116.0 *F which is within regulatory range of 105*F and 120*F. LPA's observed a pull alarm system, fire extinguishers inspected on 6/4/2021 and current, smoke and carbon monoxide detectors, central heating and air in the facility. LPA's 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.


LPA's reviewed four (4) staff training records, resident medication administration records, four (4) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.


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

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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