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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701299
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:04:01 PM

Document Has Been Signed on 11/21/2023 03:04 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: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: DATE:
11/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Luis ManiquizTIME COMPLETED:
03:15 PM
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On 11/20/2023 at 1:00 PM, 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 Lee met with administrator, Luis Maniquiz, who assisted LPA Lee in today’s inspection.

The licensee will be the administrator of this facility. Administrator certificate number # 6049248735 and will expires on 06/21/2024. Facility has a 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. This Applicant is seeking licensure for a 4-bed Adult Residential Facility (ARF) to accept and retain adult residents at any given time. The facility will not employ staff who are live-in caregivers but have staff working shifts throughout the day/night for proper 24-hour care and supervision. There were no residents in care at this time.

A tour of the kitchen area was toured. A review of food supply was conducted to ensure a 2-day perishable and 7-day non-perishable food supply was available. This facility will have a locked medication cabinet located in the kitchen. A first aid kit was observed and had all the required components. Fire extinguisher was located in the common area and is in good repair. A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair. LPA Lee observed activities such as, books, magazines, and board games in the common area made accessible to clients. A tour of the backyard was conducted and no hazards present. Perimeter gate was observed to be in good repair. LPA Lee observed patio covering in good repair. A tour of garage was conducted. A washer and dryer were identified. Detergent, toxins, and other cleaning supplies were observed to be locked and made inaccessible. A tour of the client bedrooms was conducted. Furniture and furnishing were observed to meet the client needs. A linen closet was in the hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time. Hot water temperature was taken to ensure that it was in within 105-120 degrees, and it measured at 116.3 degrees Fahrenheit. Fire extinguisher and carbon monoxide is in good repair. The deficiencies the from last pre-licensing on 11/13/2023 has been corrected:


Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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: 11/21/2023
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·LPA Lee observed activity supplies made available for clients at this time. COMPLETED
· LPA Lee observed the numerous exposed roofing nails were sealed and made inaccessible to clients at this time. COMPLETED

Applicant was advised If any changes in plan of operation occur during the Alta Regional Center vendorization process, they will need to submit the updated plan of operation, which will also need to be reviewed and approved by the Department.

Component III was completed at this time with the Applicant. The applicant has passed the pre-licensing component of the application process. LPA Lee will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. 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: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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