<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701302
Report Date: 08/12/2024
Date Signed: 08/12/2024 11:26:45 AM


Document Has Been Signed on 08/12/2024 11:26 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: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:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Elaine TolentinoTIME COMPLETED:
11:45 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) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by facility staff and later met by Administrator Elaine.

LPA Valerio and facility staff toured the facility to ensure compliance of Title 22 regulations. LPA Valerio inspected residents bedrooms, which were observed to be free from odors, clean, and fully furnished. Resident bathrooms were observed to be clean and free from debris. The kitchen was observed to have medications, sharps, and cleaning supplies locked and inaccessible to residents. The facility was observed to have an adequate food supply and an emergency supply of food. Staff were observed sitting outside with residents, assisting residents with craft activities, assisting residents with ADLs, cleaning, and preparing meals. The backyard was observed to have a shed utilized for storage. There is no live in care staff; however, there is a staff designated room for staff breaks.

LPA Valerio requested the following annual documentation be sent to LPA: LIC 500, LIC 308, LIC 610, and copy of Liability insurance

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. 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: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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 1