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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000405
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:34:15 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:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Farah Cuccia-Razo (Admin)TIME COMPLETED:
03:00 PM
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Community Care Licensing (CCL) staff Danielle Meadows and Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 7/22/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. Staff and LPA met with Farah Razo (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection CCL staff and LPA completed required COVID-19 testing protocols, and self-screened for symptoms of COVID-19. Additionally LPA contacted facility and conducted a pre-screening call prior to inspection. CCL staff and LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical masks and N-95. Additionally, LPA CCL staff were screened by admin and answers were documented in their visitor screening log.

LPA, Danielle and Admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) of four (4) resident bedrooms, one (1) of one (1) staff room three (3) of three (3) bathrooms, kitchen, storage, garage and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

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: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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