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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701182
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:52:26 PM

Document Has Been Signed on 08/09/2023 03:52 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: 2DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rebecca HammettTIME COMPLETED:
04:00 PM
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On 8/9/23 at approximately 11:30am Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with the Administrator, Rebecca Hammett, and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility currently provides care for 1 ambulatory resident, 1 non ambulatory resident, 0 hospice, and 0 bedridden residents.

Facility Observation: The facility has an open floor plan. Upon entry the residents were preparing for day program. Confirming their lunches were made. R2 was picked up soon after. R1 was on the sofa looking at a book. R1 shared the book with LPAs and chatted for a bit. R1 showed LPAs the bedroom which was decorated with personal items. R2’s bedroom was filled with personal art work.

Water temperature in common bathroom reads 108.3 F* which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. The fire extinguisher was checked and in compiance. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care.

Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility has appropriate internet access available for resident use. Facility conducts quarterly fire drills.



SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 CARE
FACILITY NUMBER: 342701182
VISIT DATE: 08/09/2023
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2 of 2 resident files and 4 of 8 staff files were reviewed and found to have the necessary requirements.

LPA requested and received an updated copy of LIC 308, LIC 500, Liability Insurance and Surety Bond.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit, Exit interview was held and a report and appeal rights were given to Administrator Rebecca Hammett.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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