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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701046
Report Date: 10/07/2024
Date Signed: 10/07/2024 02:30:26 PM

Document Has Been Signed on 10/07/2024 02:30 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:MACHICO PLACE, LLCFACILITY NUMBER:
342701046
ADMINISTRATOR/
DIRECTOR:		GREEN, ANGELINA GFACILITY TYPE:
735
ADDRESS:10326 MACHICO WAYTELEPHONE:
(916) 714-9025
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Angelina Green TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Administrator Angelina Green.

LPA Valerio and Administrator Angelina toured the facility to ensure compliance of Title 22 regulations. LPA observed 1 staff and 1 resident present in the facility. Other residents were out for the afternoon. LPA Valerio observed common areas to be clean, fully furnished, and organized. LPA Valerio observed pictures of resident outings, items for activities, and areas for indoor and outdoor activities. Resident bedrooms were fully furnished with quality linens, observed to be clean, and free from odors. Hot water was measured at 106.1 degrees F. Resident bathrooms were sanitary and stocked with hygiene supplies, paper towels, toilet paper, hand soap, and sanitizer. Medications, sharps, and cleaning supplies were locked and inaccessible to residents in care. The facility met food requirements. Snacks and other food items are made available to residents at any time. The facility air conditioning appeared to be working and be set at a comfortable temperature. The facility fire extinguisher was within compliance with it's last check on 08/16/24. The outdoor area was observed have a shaded area for sitting or outdoor activities. No emergency exits were obstructed.

LPA Valerio observed two (2) resident files and two (2) staff files. Resident files were observed to be up to date. Staff files were within compliance and were observed to have required annual training.

LPA Valerio obtained the following annual documentation: LIC 500, LIC 308, and copy of the surety bond. LPA Valerio requested the following annual documentation be sent: LIC 610D

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was held with Administrator Angelina Green, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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