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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000405
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:38:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ELIM OAKSFACILITY NUMBER:
347000405
ADMINISTRATOR:LEE, JENNIFERFACILITY TYPE:
740
ADDRESS:124 RAEANNE LANETELEPHONE:
(916) 989-4232
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 6DATE:
05/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Farah Razo (Designated Admin)TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit regarding staff being fingerprint cleared at facility. Community Care Licensing (CCL) was informed that some staff are possibly not finger print cleared to facility, which resulted in today’s visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA was greeted by Farah Razo (Designated Admin) upon arriving at facility, and was screened.

During visit, LPA conducted interviews with four (4) of four (4) staff, reviewed six (6) of eighteen (18) staff records, and toured facility. LPA asked Farah if any new staff have been hired that have not been able to get cleared, and was informed no new hires at this time. LPA brought Staff Roster and viewed that all staff working were associated to facility. LPA had Farah update staff roster and LPA will disassociate identified individuals upon returning to office. Through records reviewed and interviews conducted, LPA did not suspect unassociated staff to be working at facility at this time. All six records were up to date, with current Background Clearance Transfer Request forms (LIC 9182) and Criminal Record Statement (LIC 508).

LPA received updated Designation of Facility Responsibility (LIC 308) during today's visit.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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