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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701006
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:19:00 PM

Document Has Been Signed on 07/12/2024 01:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PERPETUAL MANORFACILITY NUMBER:
342701006
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:9449 PINOT BLANC CT.TELEPHONE:
(916) 509-9668
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Angelica FernandezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 7/12/24, at 9:45am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct a required annual visit. LPA met with Administrator Angelica Fernandez (ADM), and stated the purpose of the visit.

LPA and ADM toured the facility to ensure compliance of Title 22 regulations. The facility is a single story home located in a residential neighborhood. LPA observed resident bedrooms, bathrooms, common areas, kitchen, dinning room, and exterior areas. Resident bedrooms were observed to be clean and spacious enough to accommodate residents' belongings. The two bathrooms were observed to be clean and equipped with grab bars and non-skit flooring. Common areas were furnished, clean and free of obstruction.

LPA observed the temperature inside the facility was measured at 72*F. The hot water was measured at 107*F. Facility maintains 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 residents in care. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Smoke detectors and carbon monoxide were tested and observed to be operable during this visit.

Residents were observed watching television, eating lunch, and inside of their room. LPA also observed two new staff being trained by staff on duty. LPA reviewed 5 staff files and 6 resident files. Technical assistance was provided to annually update medical assessments for dementia residents. All staff files reviewed had necessary training and completed files. Medication review was conducted with 2 of 6 residents and no issues were noted. Emergency drills were conducted and up to date. LPA requested current Liability Insurance, LIC500 and LIC308.

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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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