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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701109
Report Date: 12/13/2021
Date Signed: 12/13/2021 09:32:18 AM

Document Has Been Signed on 12/13/2021 09:32 AM - 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:MELYNDA'S 2 CARE HOME LLCFACILITY NUMBER:
342701109
ADMINISTRATOR:TAGUINOD, MELYNDAFACILITY TYPE:
735
ADDRESS:9085 ANCESTOR DRTELEPHONE:
(516) 270-4416
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 0DATE:
12/13/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melynda TaguinodTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility to conduct a pre-licensing inspection. LPA Valerio introduced herself, explained the purpose of the visit, and was met by Administrator Melynda Taguinod. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff have not displayed any signs or symptoms of COVID-19 in the last 10 days.
 
LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA reviewed and approved the LIC 808 mitigation plan during the visit. The facility backyard has a pool surrounded by a locked fence. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. Facility has a 30 day supply of PPE.
 
LPA observed the temperature inside the facility was measured at 72*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 115.0*F. Facility has a place for nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area, cleaning supplies, and staff files to be locked. Resident rooms was sanitary and had the required furniture and furnishings. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 12/01/2021. Emergency disaster plan and necessary signage posted and available. First aid kits and emergency supply of food were observed to be fully stocked. LPA observed no obstruction of emergency exits inside or outside of facility.
 
Pre-Licensing is complete and this facility has no deficiencies. A Component III was completed at this time with the Applicant. Administrator Melynda had no further questions. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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