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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701046
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:25:40 PM

Document Has Been Signed on 10/22/2021 03:25 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:MACHICO PLACE, LLCFACILITY NUMBER:
342701046
ADMINISTRATOR:GREEN, ROBERT JFACILITY TYPE:
735
ADDRESS:10326 MACHICO WAYTELEPHONE:
(916) 714-9025
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
10/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robert GreenTIME COMPLETED:
04:00 PM
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On 10/22/2021 at 1:30pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a Pre-Licensing Inspection. LPA was allowed entry into the home that will be licensed for a capacity of 4 ambulatory clients. Client bedrooms are approved for ambulatory use only. LPA met with Robert Green, Applicant who assisted with today’s visit. Robert Green Administrator Certificate expires 10/8/2021. Angelina Green will be the designated Administrator who holds current certification #6053508735 and expires on 2/16/2023.

LPA and Robert Green toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are four clients at this time.

LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 113.4 degrees Fahrenheit which is within the required range of 105-120*F. The temperature inside the facility measured at 72.0 degrees Fahrenheit which is within the required range of 68-85*F. LPA 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 kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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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: MACHICO PLACE, LLC
FACILITY NUMBER: 342701046
VISIT DATE: 10/22/2021
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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.

LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPA 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 Pre-licensing visit, it was determined that this facility was found to be in compliance at this time.

Component III conducted - Licensure pending.

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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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