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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701040
Report Date: 05/27/2021
Date Signed: 05/27/2021 02:18:35 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:BRUCEVILLE POINTFACILITY NUMBER:
342701040
ADMINISTRATOR:HOSTETTER, ERICFACILITY TYPE:
740
ADDRESS:9730 BACKER RANCH ROADTELEPHONE:
(916) 226-5300
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:200CENSUS: 0DATE:
05/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eric Hostetter, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Charlie Yang and Tung Truong arrived at this facility announced on 05/27/2021 at 9:00 AM to conduct a pre-licensing inspection. LPAs met with the facility designated Administrator Eric Hostetter and explained the purpose of the visit. The facility designated Administrator Eric Hostetter assisted with today’s visit.

Administrator Eric Hostetter holds a current certificate # 6021870740 which will expire on 01/03/2023. The LPAs toured and inspected the physical plant inside and outside with the administrator Eric Hostetter to ensure there were no health and safety concerns on 05/27/2021 at 10:00 AM. LPA observed there were no residents in care at this time.

The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided it to LPA Truong for approval on 5/27/2021. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. The theater, art studio, and fitness room were reviewed to make sure that all components were functional and in good repair at this time.



Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BRUCEVILLE POINT
FACILITY NUMBER: 342701040
VISIT DATE: 05/27/2021
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A review was conducted of the apartment sizes and different layouts. The med rooms, located primarily on the first floor, was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPAs observed required furniture and lighting throughout the facility. The hot water temperature was measured at 117.5*F during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 71*F which was within the required range of 68-85*F.

LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kits were available in the kitchen and med rooms. LPAs observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPAs observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPAs observed the area where the staff and resident files were locked and readily available for review.



Based on a review of this facility during this Prelicensing visit, it was determined that this facility was found to be in compliance at this time. LPAs discovered that the facility designated Administrator Eric Hostetter has completed Component III before and will therefore waive this requirement.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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