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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701247
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:17:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/29/2024 04:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:R & A CRUZ CARE HOME LLCFACILITY NUMBER:
342701247
ADMINISTRATOR/
DIRECTOR:		CRUZ, ANNABELLEFACILITY TYPE:
735
ADDRESS:9432 SAGE CREEK COURTTELEPHONE:
(916) 793-4991
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 3CENSUS: 1DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:Annabelle CruzTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 5/29/2024, at 3:01pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their required annual inspection visit. Note that this visit was conducted at the same day as their post-licensing visit. The CARE Tool was utilized during their post-licensing visit. LPA met with the facility administrator, Annabelle Cruz and explained the purpose of the visit. At this time, this facility is undergoing vendorization from Alta California Regional Center (ACRC). Currently, there is one respite resident staying at this facility under Family Home Agency (FHA).

LPA and Administrator conducted a physical inspection including but not limited to the common areas, bathrooms, residents room and outdoor areas. The facility is a one-story home located in a residential neighborhood. Outside of the facility was observed to be free of obstruction. LPA observed outdoor furniture for outdoor activities. LPA also observed security cameras outside of the home. No bodies of water was observed at this time.

LPA observed inside the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed 3 resident bedrooms and 2 resident bathrooms. One of the bathroom is located in one of the bedrooms. LPA observed garbage cans without lid during bathroom inspection. Technical advisory was provided for facility to obtain proper garbage container per regulation. Kitchen was observed to be clean and sanitary. Facility maintain a sufficient 2-day perishable and 7-day non-perishable food supplies. Food supplies were observed to be stored adequately. Refrigerator and freezer were observed to have adequate space to accommodate food supplies and are within regulatory temperature of 45 degress F for the refrigerator and 0 degress F for the freezer.

Fireplace was observed to be screened. Medications and sharp objects were observed to be locked and inaccessible to resident. Toxins and cleaning supplies are kept locked in the laundry room and inaccessible to resident. Facility keeps a firearm and is kept locked in a locked box, inside a locked cabinet in the staff bedroom and inaccessible to resident.

{Con't to LIC809-C}
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: R & A CRUZ CARE HOME LLC
FACILITY NUMBER: 342701247
VISIT DATE: 05/29/2024
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LPA observed the following posted in the facility: See Something Say Something complaint poster, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.
LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been last serviced on 2/8/2024.

Administrator has current Administrator Certificate and current first aid/CPR certificate. Technical advisory was provided to the Administrator to maintain a complete personnel records including on the licensee and administrator. Per interview with the Administrator, facility does not have liability insurance at this time.

No deficiencies are cited during today's inspection.

Exit interview and copy of report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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