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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701120
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:06:02 PM

Document Has Been Signed on 03/03/2022 04:06 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:FREDERICKSON HOME IIFACILITY NUMBER:
342701120
ADMINISTRATOR:FREDERICKSON, VALERIEFACILITY TYPE:
735
ADDRESS:5320 MATINA DR.TELEPHONE:
(916) 947-8572
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
03/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Valerie Frederickson, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 3/03/2022 at 1:20 PM to conduct a pre-licensing inspection. Prior to entering the facility, LPA Truong called and spoke to Administrator Valerie Frederickson to let her know LPA is currently at the facility. Administrator Valerie Frederickson advised LPA she will arrive at the facility shortly. LPA was screened for COVID-19 symptoms and temperature taken prior to entering the facility. LPA met with Administrator Valerie Frederickson and explained the purpose of the visit. LPA was also met by current Licensee Antoniette Astorga.

Administrator Valerie Frederickson holds a current certificate # 6010357735 which will expire on 02/016/2024. It was learned that this facility will be licensed to serve up to 6 non-ambulatory clients, of which 1 can be bedridden. LPA Truong toured and inspected the physical plant inside and outside with the Administrator Valerie Frederickson to ensure there were no health and safety concerns. LPA observed there were six (6) clients in care at this time.

LPA observed the kitchen area, pantry, dining area, bedrooms, bathrooms, storage areas, and laundry area. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 115.7 degrees Fahrenheit which is within the required range of 105-120 degrees Fahrenheit. The temperature inside the facility measured at 70 degrees Fahrenheit which is within the required range of 68-85 degrees Fahrenheit. 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 was up to date.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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: FREDERICKSON HOME II
FACILITY NUMBER: 342701120
VISIT DATE: 03/03/2022
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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 also conducted the inspection tool.

The facility had Covid-19 posting throughout the facility. The facility had submitted the Mitigation Plan to Licensing for review. 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.

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 was conducted and completed during today's Pre-licensing visit.

Exit Interview was conducted with Administrator Valerie Frederickson and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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