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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701182
Report Date: 08/11/2022
Date Signed: 08/12/2022 07:54:08 AM

Document Has Been Signed on 08/12/2022 07:54 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:ELLA ROSE CAREFACILITY NUMBER:
342701182
ADMINISTRATOR:HAMMETT, REBECCAFACILITY TYPE:
735
ADDRESS:9460 MAINLINE DRTELEPHONE:
(916) 316-6213
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: DATE:
08/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rebecca HammondTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) R. Campbell, conducted an announced Pre-licensing visit on 08/11/2022 with facility Administrator and Licensee applicant Rebecca Hammond. LPA arrived at facility at 1:40 pm. Administrator and Licensee accompanied LPA on facility tour. As of today, current census is 0 residents. The facility is a 4 bedroom, 2 1/2 bath house with a living room, dining room, kitchen, and laundry room. Residents have access to all areas. Upon entry, LPA’s temperature was taken and LPA was screened for COVID signs and symptom questions.

LPA toured the facility. No residents were present. LPA measured the hot water to be 117 degrees in hallway bathroom within regulatory range of 105 *F and 120 *F.

Observed medication area that is locked with proper storage. COVID Precautions in place including signage, PPE storage and 30-day supply. Isolation rooms designated. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in place in kitchen and laundry room and fully charged. A copy of this report was provided to Rebecca Hammett immediately after inspection.

There were no deficiencies observed during today's Pre-licensing visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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