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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701247
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:22:45 PM

Document Has Been Signed on 04/13/2023 01:22 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:R & A CRUZ CARE HOME LLCFACILITY NUMBER:
342701247
ADMINISTRATOR:CRUZ, ANNABELLEFACILITY TYPE:
735
ADDRESS:9432 SAGE CREEK COURTTELEPHONE:
(916) 793-4991
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 3CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Annabelle CruzTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived announced to conduct a prelicensing visit. LPAs Moleski and Lund met with Annabelle Cruz and explained the purpose of the visit. There is one client in care at the home through Enriching Lives.

The home has a fire clearance for two ambulatory residents in bedrooms 4 and 2, and one non-ambulatory resident in bedroom 3.

LPAs Moleski and Lund toured the home with Cruz.. LPAs observed the kitchen area, dining area, common areas, bedrooms, bathrooms, garage and outdoor areas. Furniture and fixtures appeared sufficient to meet the needs of the residents. Water temperature was tested and was within the required range of 105 and 120 degrees. An up-to-date fire extinguisher was observed. Smoke and carbon detectors were observed and tested to be in good working order. LPAs Moleski and Lund observed locked cabinets for the storage of toxins, cleaning solutions and knives.

Component III was completed during this visit. An exit interview was conducted and a copy of this report was left with Cruz.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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