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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701155
Report Date: 12/05/2022
Date Signed: 12/05/2022 10:29:32 AM

Document Has Been Signed on 12/05/2022 10:29 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:MILESTONE CAREHOME INCFACILITY NUMBER:
342701155
ADMINISTRATOR:MERCADO, JENNIFERFACILITY TYPE:
735
ADDRESS:9001 GENERATIONS DRTELEPHONE:
(916) 585-1255
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 1DATE:
12/05/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Mercado - AdministratorTIME COMPLETED:
10:30 AM
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Licensing program Analyst (LPA) Ruth Wallace conducted unannounced post licensing inspection visit. LPA explained purpose of visit to administrator.

LPA and administrator conducted a tour inside and outside of the care home. LPA observed the back yard with a secure fence, there was a table, umbrella, and adequate outdoor seating, and no pool or bodies of water were observed. LPA observed the back yard and perimeter of the care home to be free of clutter and debris and windows and screens were in good repair Inside the care home, LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed bedrooms and living areas to be adequately furnished and LPA observed adequate supply of linens on hand. Tested water temperature in resident bathroom at 115.3 degrees F. LPA observed bathrooms to be in sanitary condition and maintained. Cleaning supplies and chemicals are stored in a locked cabinet.

LPA observed a sufficient supply of perishable and non-perishable food supply on hand, and there is a sufficient supply of eating, serving, and food preparation materials on hand as well. LPA observed a first aid kit and fire extinguishers last serviced on 3/10/2022 and a fire clearance is for 4 ambulatory clients. Smoke detectors are hard wired and care home has a functioning carbon monoxide detector.
Emergency exit and phone number are posted. LPA was sent a photo of all required postings. There are supplies and materials for activities. Medications and confidential paperwork will be stored in separate locked cabinets.
LPA reviewed one (1) resident file and three (3) staff files. A review of staff records indicates that all facility staff & other individuals who require caregiver background checks are fingerprint cleared and to the facility. LPA verified staff training for staff file reviews and all 3 staff have current First Aid Certificates.

No deficiencies were found or cited during today's inspection visit. Exit interview held with administrator and a copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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