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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 10:44:10 AM

Document Has Been Signed on 12/05/2022 10:44 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Jennifer Mercado - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced case management incident visit. LPA explained purpose of visit to administrator.

R1 was placed in facility on 11/5/2022 and had never lived in licensed facility before. Incident occurred on 11/16/22 at doctor's appointment. R1 left doctor's appointment and ran away from staff. R1 was followed until R1 was out of sight. 911 was called and R1 returned within ten minutes of leaving.

R1 returned to car and returned to facility unharmed. Two staff will accompany R1 at any appointment until R1 is comfortable or unnecessary.

No deficiencies cited on today's 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: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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