342701336-4-2-2024-27-AS-KVIA-D3XT6C-20240402142652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701336
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:26:59 PM

Document Has Been Signed on 04/02/2024 02:26 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:	ELIXIR CARE HOME		FACILITY NUMBER:	342701336
ADMINISTRATOR:	DULAY, MARIA G		FACILITY TYPE:	740
ADDRESS:	1440 HOOD ROAD		TELEPHONE:	(916) 565-1468
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	6	CENSUS: 4	DATE:	04/02/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria (Gloria) Dulay, Administrator/Licensee		TIME COMPLETED:	02:30 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	On 04/02/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a pre-licensing inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Licensee/Administrator. LPA met with Maria Gloria Dulay and a brief interview followed. LPA noted the Administrator/Licensee, Maria Gloria Dulay's certificate, # 7001763740 expired on 11/10/25. The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. LPA inspected an additional pantry and 7 items were randomly selected. All had valid expiration dates. LPA inspected 6 resident bedrooms and 2 staff rooms and an office. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels and trashcans with lids in the bathrooms. The hot water temperature was measured at degrees Fahrenheit and was in compliance. The 2 fire extinguishers were last serviced on Sentinel Fire Co. on 02/9/24 and were also in compliance. The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There were shaded patio areas in the front and rear of the facility with furniture to accommodate the needs of residents in care. LPA tested both of the gates at either end of the facility. One had a self-closing mechanism, the other did not, however, when this was brought to the Licensee / Administrator's attention, she had it immediately repaired prior to this LPA finishing the inspection LPA toured the garage as well and observed refrigerators and a food supply for staff as well as a separate location for staff to rest during their scheduled breaks.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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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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: ELIXIR CARE HOME	FACILITY NUMBER: 342701336
	VISIT DATE: 04/02/2024

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The LPA observed medications were stored in a large locked metal cabinet in the kitchen and inaccessible to residents in care. Medications were primarily the pill packs provided by the pharmacy. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance. LPA spent time reviewing PRN documentation to ensure that staff documented the results of PRN administration. Licensee / Administrator added an additional column to their log sheets to ensure that staff made the appropriate notes regarding medication effectiveness.

LPA reviewed 2 resident records and 1 staff file and all the required information was present in each.

LPA completed Comp III with Licensee Administrator.

According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's visit. This facility passed its pre-licensing inspection.

A copy of this report was provided.

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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