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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 04/27/2022
Date Signed: 04/29/2022 08:49:57 AM


Document Has Been Signed on 04/29/2022 08:49 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:BEATRICE SENIOR CAREFACILITY NUMBER:
342701159
ADMINISTRATOR:MITITI, BIANCAFACILITY TYPE:
740
ADDRESS:8901 MELODIC CTTELEPHONE:
(916) 270-3961
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
04/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Beatrice Clark, LicenseeTIME COMPLETED:
04:20 PM
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On 04/27/2022 at 2:00 pm Licensing Program Analysts (LPAs) T. White and R. Campbell arrived announced to conduct a prelicensing inspection with applicant Beatrice Clark for this residential facility application. Administrator Certification #6052573740 that expires on 08/09/2023.

LPAs conducted an inspection of facility including common areas, resident bathrooms, kitchen, dining room, storage, and outside yard area. Requested capacity is 6 residents. The facility is clean and in good repair in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food and are secured. There are no bodies of water on the premises. Smoke alarm was tested and operational. Fire extinguisher was in compliance and serviced March 01, 2022 and facility has carbon monoxide detectors.

Adequate number of bedrooms (6) for capacity requested. Facility has supply of bedding and towels. Furniture appears appropriate in bedrooms. There is adequate closet/drawer space available. There are plenty of bathrooms for number of residents. Non-skid surfaces/mats were noted in the shower. Kitchen appears to be clean, well supplied with equipment. Facility has current staff files and adequate supply of forms. First aid kit was present at the facility. Laundry equipment present, working telephone, emergency lighting. Water temperature was measured at 120 degrees F.

LPAs conducted Component III presentation.

Exit interview conducted and copy of this report was provided to applicant for signature. Report sent to the applications unit as this facility is ready for licensure.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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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