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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701302
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:38:11 PM


Document Has Been Signed on 05/16/2024 12:38 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: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:
05/16/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Elaine TolentinoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a Post-Licensing Inspection. LPA Valerio was met by Administrator Elaine Tolentino, and explained the purpose of the visit.

LPA observed 6 residents and 2 staff present in the facility. LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA observed the common room area, kitchen, residents bedrooms, resident bathroom, staff bedroom, garage area, and exterior area. Common room area was observed to be fully furnished and equipped with areas to conduct indoor activities. Residents were observed living to music while watching live motion pictures, enjoying a snack, taking a nap, completing ADLs, or visiting with family. Resident bedrooms were observed to be clean, free from odors, and no emergency exits being obstructed or blocked. Resident bathrooms were observed to be stocked with paper towels, toilet paper, hand soap, skid mats, hand rails, and a trash can. The facility was observed to have an extra supply of linen bed sheets, bed comforters, and hygiene supplies. The staff bedroom was observed to be only used for staff and free from resident belongings. The kitchen area was observed to be clean. The facility was observed to have an adequate food supply in addition to an emergency supply of food for staff and residents. The exterior shed was observed to be utilized for storage. Exit walkways were not obstructed.

LPA reviewed 2 resident and 2 staff files. Files were observed to be completed with required documents. Resident files were observed to have necessary documents. Staff files were observed to have fingerprint clearances and yearly training.

LPA Valerio and Administrator Elaine discussed Title 22 regulations, recommendations for resident documentation, exceptions and waivers, and reviewed Medication Administration Records.

Per California Code of Regulations (CCR) - Title 22, Division 6, no deficiencies were observed. An exit interview was held, 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: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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