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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701006
Report Date: 07/18/2023
Date Signed: 07/18/2023 10:07:41 AM


Document Has Been Signed on 07/18/2023 10:07 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: 5DATE:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Angelica FernandezTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual visit. LPA met with Administrator Angelica Fernandez, and explained the purpose of the visit.

LPA and facility staff toured the facility to ensure compliance of Title 22 regulations. LPA observed resident bedrooms, bathrooms, common areas, kitchen, dinning room, and exterior areas. Resident bedrooms were observed to be clean and organized. Bathrooms were clean and observed to have soap, hand sanitizer lotion, paper towels, trash cans, and hand rails. All common areas of the home were clean, organized, and had necessary furniture.

LPA observed the temperature inside the facility was measured at 72*F. The hot water was measured at 105.3*F, which is within the regulatory range of 105 degrees F - 120 degrees F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area, sharps, and chemicals to be locked and inaccessible to clients. LPA Valerio observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

Residents were observed watching television, eating breakfast, working on puzzles, and inside of their room. LPA reviewed staff and resident files. All 5 resident files were completed and up to date. All staff files reviewed had necessary training and completed files. Emergency drills were conducted and up to date.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, and copy of report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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