342701143-2-15-2022-27-AS-MJEN-CBNQY6-20220215113438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701143
Report Date: 02/15/2022
Date Signed: 02/15/2022 11:34:51 AM

Document Has Been Signed on 02/15/2022 11:34 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:	GROVE ST CARE HOME, LLC		FACILITY NUMBER:	342701143
ADMINISTRATOR:	SANDOVAL, MANUEL ALBERTO		FACILITY TYPE:	740
ADDRESS:	9189 GROVE ST.		TELEPHONE:	(916) 686-2859
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Manuel Sandoval		TIME COMPLETED:	11:45 AM

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Licensing Program Analysts (LPAs) Avelina Martinez and Maja Jensen arrived unannounced to conducted a Pre-Licensing, Change of Ownership, Inspection of the facility to ensure compliance with Title 22 regulations. LPA Maja Jensen called Current Licensee Jim Jones and completed COVID screening questions. There are no active COVID cases in the facility at this time. LPAs Avelina Martinez and Maja Jensen met with prospective licensee Manuel Sandoval who assisted LPAs in today’s inspection. Manuel Sandoval holds a Residential Care Facility for the Elderly Administrator's Certificate # 6049137740 with expiration date 8/12/22.

Facility has a fire clearance for 5 non-ambulatory residents and one bedridden resident.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen.

Physical Plant:

The facility was toured both indoor and outdoors with Manuel Sandoval and Jim Jones. Adequate signage was posted related to COVID precautions, Ombudsman and "see something, say something. Resident rights signage was not observed.The fire extinguisher was last serviced in August of 2021 and is in compliance. The carpet throughout the facility was clean and the facility was free of odor. The facility has 5 bedrooms, all of which had adequate furniture including chairs, night tables, dressers for resident belongings. The facility temperature was comfortable at 75 degrees. The water temperature in the bathrooms was measured at 117.8 degrees and 114.8 degrees which falls within the required range of 105-120 degrees. One bathroom was observed to lack adequate lighting as a result of several light bulbs being burnt out. The dining area has a window that is missing that currently holds an AC unit and has been covered with cardboard. The garage has an unobstructed path cleared for emergency exit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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: GROVE ST CARE HOME, LLC	FACILITY NUMBER: 342701143
	VISIT DATE: 02/15/2022

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Food Services:

The facility has a refrigerator for residents and a refrigerator for staff in the kitchen. There is also a refrigerator and freezer in the garage. A seven day supply of non-perishable foods and 2 day supply of perishable food was observed. There was an adequate supply of fresh fruit and vegetables. Expired yogurt was observed in the refrigerator and expired canned beans were observed in the pantry. Knives were observed to be kept in a locked cabinet.

Care & Supervision:

Adequate PPE was observed. A first aid kit was observed to be complete and is kept locked with medications. Adequate staffing was on hand for care of the residents.

Records Review:

An acceptable plan of operation and admission agreement was observed. An emergency disaster plan was observed and adequate.

Medication:

Medications were observed to stored in a locked cabinet. Within the cabinet each resident has a dedicated shelf.

The applicant has not passed the pre-licensing component of the application process. The following issues will need to be corrected within 30 days or by March 17, 2022.

Replace window in dining room that faces the backyard. Replace burnt out light bulbs in bathroom.

Remove all expired food products from refrigerator and pantry. An exit Interview was conducted with Manuel Sandoval and a copy of this report was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

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