<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701182
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:20:54 PM

Document Has Been Signed on 12/20/2022 04:20 PM - 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: 1DATE:
12/20/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Allison Lopez, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA Renee Campbell) conducted a Post-Licensing visit on today's date. LPA was met by Caregiver Allison Lopez and conducted a tour of the interior and exterior areas of the facility. There was 1 (one) resident in the facility.

Client bedrooms, bathrooms, hallway, kitchen, family room and dining area were observed. Backyard was toured and observed clean and clutter free. The temperature in the home was a comfortable 68 degrees Fahrenheit. Medication, knives and toxins were all secured in cupboards and cabinets and inaccessible to clients. Food supply was checked, and LPA observed at least 1-week and 2-day supply of nonperishable and perishable foods, respectively.

The facility had the required carbon monoxide detectors throughout the home. Smoke detectors are operable. Fire extinguishers were serviced on 05/18/2022. First aid kit was observed and had the required scissors, thermometer and tweezers. The last fire drill was 12/15/2022.

LPA reviewed two (2) Staff records and one (1) client record. All files were complete. Staff are fingerprint cleared and first aid certified.


No deficiencies were cited during this inspection.
Exit interview conducted. A copy of this report was left with the Administrator
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1