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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701022
Report Date: 06/06/2023
Date Signed: 06/06/2023 04:47:18 PM


Document Has Been Signed on 06/06/2023 04:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SERRANO GUEST HOME 2FACILITY NUMBER:
342701022
ADMINISTRATOR:ERIC SERRANOFACILITY TYPE:
740
ADDRESS:8774 KELSEY DR.TELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required visit. LPA met with licensee Lilibeth and explained the purpose of the visit.

LPA completed the inspection care tool. LPA and Licensee toured the facility to ensure compliance with Title 22 regulations.

Administrator Eric Serrano has an active administrator certificate 6056999740 with an expiration date of 08/26/2024. LPA observed 2 staff on shift and confirmed those individuals were fingerprinted cleared and associated to the facility. Facility staff was observed assisting residents with ADLs, singing karaoke with resident, outside agency visits, and preparing dinner. Medications, sharps, and toxins were observed to be locked away and inaccessible to residents in care. Emergency exits were clear from obstructions. Furniture and furnishings were in good repair in common areas, resident bedroom, and bathrooms. Staff office and bedrooms are clear from obstructions and has an approved fire clearance. Fire extinguishers are up to date with annual inspection and in working condition. LPA observed the temperature inside the facility was measured at 76 *F, which is within the required range of 68 degrees F and 85 degrees F. Hot water was measured at 110*F degrees. LPA reviewed facility records, including staff and resident files. LPA interviewed residents and staff during the visit.

LPA requested the following to be sent to LPA by 06/15/2023: LIC 500, LIC 308, LIC 610D, LIC 999, and Copy of Liability Insurance

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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