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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701302
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:56:27 PM


Document Has Been Signed on 10/31/2023 03:56 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 HOMEFACILITY NUMBER:
342701302
ADMINISTRATOR:TOLENTINO, ELAINEFACILITY TYPE:
740
ADDRESS:6813 ELVORA WAYTELEPHONE:
(916) 685-3093
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
10/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Marivic DaduyaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christina Valerio and LPA Arvin Villanueva arrived unannounced to conduct a case management visit. LPAs met with designated staff Marivic Daduya, and explained the purpose of the visit.

Licensee informed LPA that a resident's family member wanted to install a camera inside the bedroom for observation purposes due to falls. Licensee sent the request to LPA, which included information regarding the resident having a full bed rail. LPA requested a copy of the doctors orders. LPAs observed the order in the file.

LPA Valerio contacted responsible party for Resident 1 and observed the placement of the webcam video. LPA confirmed that the video respects the privacy of the roommate. LPA observed the camera in person and observed the camera to be facing towards R1's side of the room. R1's side of the room is separated by a wall. No health, safety, or personal right concerns observed.

Based on observations, records review, and interviews, no deficiencies were observed during today's visit. An exit interview was held with designated staff, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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