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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701120
Report Date: 03/29/2024
Date Signed: 03/29/2024 05:13:39 PM

Document Has Been Signed on 03/29/2024 05:13 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:FREDERICKSON HOME IIFACILITY NUMBER:
342701120
ADMINISTRATOR:FREDERICKSON, VALERIEFACILITY TYPE:
735
ADDRESS:5320 MATINA DR.TELEPHONE:
(916) 686-7358
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mavictoria Agra, CaregiverTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a required - 1 year visit on 3/29/24 at 4:00pm and met with Mavictoria Agra, Caregiver who notified Administrator regarding the purpose of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden. Licensing fees are due 3/30/24 Pin number provided as option to pay online. Administrator certificate expires 2/16/24 which is in pending status. Most recent emergency/disaster drill was conducted on 3/22/24.

LPA and Mavictoria Agra, Caregiver toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are residents participating in activities during this visit. LPA observed the kitchen area, activity areas, bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps areas to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 114.8*F which is within the required range of 105-120*F. The temperature inside the facility measured at 72*F which is within the required range of 68-85*F.

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. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and pull alarm system in the facility. LPA observed 1 client and 1 staff files and conducted interviews during this visit. Facility has central heating and air. LPA observed area where the resident files are locked and readily available for review.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FREDERICKSON HOME II
FACILITY NUMBER: 342701120
VISIT DATE: 03/29/2024
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Upon a file review the following items were discussed to be submitted by fax with any changes annually:
Designation of Administrative Responsibility LIC308-Submit
Administrative Organization LIC309-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-Submit
Surety Bond LIC402-Submit
Personnel Report LIC500-Submit
Health Screening Report-Facility Personnel LIC503-NA
Criminal Record Clearances LIS536-NA
Emergency Disaster Plan LIC610D-Submit
Facility Floor Plan/Plot Plan LIC999-Current
Admission Policies and Procedures-Submit
Articles of Incorporation/Organization, Constitution and bylaws-Submit
Bacteriological Analysis of Private Water Supply-NA
Control of Property-Submit
Exemptions/Waivers and Exceptions-NA
Fire Clearance (consistent with terms and limitations of license)-NA
First aid/CPR certificates-NA
Infection Control Plan to include any addendums-Submit
In-service Training Program-NA
Job Description/Personnel Policies-Submit
Liability Insurance-(if applicable) Submit
Licensing fees-Current
Medication Procedures-Submit
Partnership Agreement-NA
Plan of Operation to include (Restricted Health Care Plan (if applicable))-Submit
Qualifications of Administrator/Facility Manager-NA
Transportation Procedures-Submit

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited.
Exit Interview held and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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