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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701046
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:31:21 PM

Document Has Been Signed on 10/17/2023 04:31 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, ANGELINA GFACILITY TYPE:
735
ADDRESS:10326 MACHICO WAYTELEPHONE:
(916) 714-9025
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Robert GreenTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with Licensee Robert Green, and explained the purpose of the visit.

LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed resident rooms, resident bathrooms, and common areas. LPA observed resident bedrooms to have all furniture and furnishings. Resident bathrooms were clean and free from debris. All common areas were clean, organized, and free from odors. Hot water was measured at 108.6 degrees F, which is within the regulatory range. Temperature inside the facility was 73*F. Medications, toxins, cleaning supplies, and sharps were locked away and inaccessible to residents in care. Residents were observed to be in their rooms for free time or out for work program. All emergency exits were clear from obstructions. An emergency supply of food was observed. The facility was observed to have a minimum of 2 days of perishable food items and 7 days of non-perishable food items. No health or safety concerns observed.

LPA reviewed resident and staff files. Staff files were current with required training. Resident files reviewed were observed to be current with annual documentation.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed. An exit interview was held with licensee Robert, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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