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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701299
Report Date: 11/13/2023
Date Signed: 11/13/2023 10:02:41 AM

Document Has Been Signed on 11/13/2023 10:02 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EVA LUIS RESIDENTIAL IIFACILITY NUMBER:
342701299
ADMINISTRATOR:MANIQUIZ, LUISFACILITY TYPE:
735
ADDRESS:8106 SAN REMO WAYTELEPHONE:
(916) 346-5602
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: 0DATE:
11/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Luis ManiquizTIME COMPLETED:
10:15 AM
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On 11//13/2023 at 8:23 AM, Licensing Program Analyst (LPA) Pang Lee arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Pang Lee met both licensee/administrator Luis Maniquiz and Eva Maniquiz. Administrators assisted LPA Lee in today’s inspection. This Applicant is seeking licensure for a 4-bed Adult Resident Facility (ARF), level 3, to accept and retain adult clients at any given time. The facility will not have a live in staff, but have staff on shift 24/7. There were no clients at this time.

The facility has fire clearance for 3 ambulatory clients and 1 non-ambulatory client. Bedrooms 1, 2, and 3 are for ambulatory clients and bedroom 4 is for non-ambulatory client. Luis Maniquiz will be the Administrator of this facility. The facility administrator’s certificate # 6049248735 is current, and it expires on 06/21/2024. The facility has an infection control plan completed and provided to Licensing for approval.

LPA Lee inspected the kitchen area. Cabinets and drawers were opened and reviewed at this time. Silverware, plates, and utensils were observed to be sufficient to meet the needs of the clients at this time. Knives, cleaning agents, and bleach were observed to be locked and made inaccessible to the clients at this time. The food storage unit, facility refrigerator, was observed to be functional and in good repair at this time. Food supply was reviewed for adequate 2-day perishables and 7-day non-perishable quantities, and they both were observed sufficient. Furniture and furnishings were observed to be sufficient and in compliance at this time. The living area, dining area, and all other areas intended for client use were observed to be furnished and sufficient to meet the needs of the clients at this time. LPA Lee observed a telephone made available to clients in the common area. The facility smoke detectors, carbon detectors and fire extinguisher were observed to be in good condition. The fire extinguisher was last serviced on 05/08/2023. Linen closet was observed sufficient supply of sheets, bedding, pillowcases, and blankets to meet the needs of the clients at this time. Client bedrooms were toured, and furniture and furnishings were observed to be sufficient and able to meet the needs of the clients.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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 2
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: EVA LUIS RESIDENTIAL II
FACILITY NUMBER: 342701299
VISIT DATE: 11/13/2023
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The water temperature measured at 118.8 degrees Fahrenheit, and the facility temperature measured at 69 degrees. LPA Lee observed the centrally stored medication areas to be locked. LPA Lee inspected the first aid kit, and it is complete. LPA lee observed facility has a designated area for clients and staff files, which is kept locked. LPA Lee observed four client files and one staff file ready for clients and staff once services begin. LPA Lee also observed required posters posted. LPA Lee did not observe activity supplies made available for clients at this time. LPA Lee toured garage and the courtyard. The emergency exit was unobstructed. LPA Lee inspected the shed in the courtyard, and it was learned that the shed will be used for storage only. LPA Lee observed the shaded patio not in good repair. LPA Lee observed numerous exposed roofing nails made accessible to clients at this time. LPA Lee will return to the facility when corrections have been made.

The Applicant has not passed the pre-licensing component of the application process. The applicant will correct the issues observed today and inform LPA when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the Applicant.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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