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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920077
Report Date: 09/21/2023
Date Signed: 09/21/2023 10:40:23 AM

Document Has Been Signed on 09/21/2023 10:40 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TATAY HOMEFACILITY NUMBER:
345920077
ADMINISTRATOR:MADRIO, BESSIEFACILITY TYPE:
734
ADDRESS:9551 SOUTH CANYON COURTTELEPHONE:
(650) 580-3896
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 5CENSUS: 5DATE:
09/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator,Bessie MadrioTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived announced for a pre-licensing inspection. LPA met with administrator Bessie Madrio. One of the applicant, Irene Monteclar was also present during today's visit. Currently there are 5 residents residing within the facility. Fire clearance was granted on for 5 bedridden residents . Administrator certificate expires on 06/07/25 #6060238735.This application is a change in ownership (CHOW) .This address is currently licensed as Lucero Manor, Facility # 342700154.

LPA conducted facility tour with administrator. Facility was inspected both indoors and outdoors. Outdoors was clean, tidy with adequate shading. Outdoor exits are clear and accessible. Indoors has the requisite rooms for activities and dining. There is a locked closet for personnel and client records. LPA inspected 2 staff files and 2 residents files. All residents and staff files have required paperwork. There were 1 LVN, 2 DSP,1 RT were working during today's visit.The emergency exiting plan and emergency phone numbers are posted. Resident rights are posted, facility visiting policy is posted, licensing complaint poster is posted. Facility has a First Aid kit and centrally stored locked cabinet for medications .LPA reviewed MAR records for 2 residents and find no errors.Facility temperature is maintained between 68 degrees and 85 degrees. The facility has adequate lighting throughout. All bedrooms have appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Water faucets are marked hot and cold with the hot water temperature at 117 degrees. Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Toxins and chemicals are appropriately locked in a cabinet. No hazardous debris noted. Kitchen is clean sanitary, and in good repair. The kitchen has operable appliances. All sharps are located in a locked drawer, and sufficient utensils are available. The 7 day non-perishable and 2 day perishable food requirement is met.

Component III was waived as the current administrator has been administrator for other ARF licensed by CCLD . LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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