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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701220
Report Date: 01/31/2023
Date Signed: 01/31/2023 09:52:16 AM

Document Has Been Signed on 01/31/2023 09:52 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:LEGENDARY WAYFACILITY NUMBER:
342701220
ADMINISTRATOR:GREEN, ROBERT J.FACILITY TYPE:
735
ADDRESS:9273 LEGENDARY CT.TELEPHONE:
(916) 248-1991
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 0DATE:
01/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Robert Green, AdministratorTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Renee conducted an unannounced pre-licensing inspection and met with Robert Green, Licensee on 1/31/2023 at approximately 8:45 am.

LPAs toured the clients bedrooms, bathrooms, dining rooms, common living areas, kitchen, and backyard. There is sufficient lighting around the facility. Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the clients. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. Hot water temperature is measured at 117 degrees Fahrenheit. There are 2-day perishables and 7-day nonperishable available for the clients. LPA observed facility to be in good repair and working condition.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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