342701302-9-26-2023-27-AS-TTRG-CW2ULE-20230926154038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701302
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:41:04 PM

Document Has Been Signed on 09/26/2023 03:41 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	A CARING HOME		FACILITY NUMBER:	342701302
ADMINISTRATOR:	TOLENTINO, ELAINE		FACILITY TYPE:	740
ADDRESS:	6813 ELVORA WAY		TELEPHONE:	(916) 685-3093
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	09/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Elaine Tolentino		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 9/26/2023 to conduct a pre-licensing inspection. Upon arrival. LPA met with Applicant Elaine Tolentino and explained the purpose of the visit. Applicant holds current administrator certification #6063633740 and expires on 8/14/2024. This Applicant was seeking licensure for a 6-bed RCFE non ambulatory with an approved hospice waiver for (6) residents at any given time. A bedridden fire clearance was also granted for (1) resident at any given time in designated bedroom #2. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry area, and garage to ensure compliance with Title 22 regulations. A review of the facility perimeter fence, side gates, and all other exits were conducted. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 107.1 degrees Fahrenheit. The temperature inside the facility measured at 75F which is within the required range of 68-85F. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A CARING HOME	FACILITY NUMBER: 342701302
	VISIT DATE: 09/26/2023

NARRATIVE

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The following forms and documents were requested to be updated and submitted into CCL at this time:
LIC 308
LIC 400
LIC 500

Based on today's Prelicensing visit this facility has been found to be in compliance at this time. Component III conducted and completed with facility Applicant at this time. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Final approval of the license by the Applications Analyst is pending.

Exit Interview

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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