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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000405
Report Date: 08/01/2024
Date Signed: 08/01/2024 04:02:23 PM


Document Has Been Signed on 08/01/2024 04:02 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Farah Razo, Jennifer LeeTIME COMPLETED:
04:10 PM
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On 8/1/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection, utilizing the care tool. LPA met with Caregiver and explained the purpose of the visit, who then contacted Staff and Administrator who arrived to the facility short afterwards.

Today's census is six residents in care, with two on hospice services. Facility is in compliance with licensure of six non-ambulatory, hospice waiver of two.

LPA and Staff conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, laundry room, staff room, garage, kitchen, bathrooms, backyard, and the common areas. LPA observed facility to have 2+ days of perishables and 7+ days of nonperishable foods. LPA observed medications, sharps and chemicals to be locked and secured and inaccessible to residents in care. LPA observed facility temperatures to be at a comfortable temperature of 72*. LPA observed five residents in the common areas participating in an activity, and one resident in their private room. LPA observed fire extinguisher to be serviced on May 31, 2024. LPA observed all indoor and outdoor pathways to be free of obstructions.

During today's inspection, LPA conducted a file review for five residents, and three personnel. LPA observed all documents present and complete.

No deficiencies observed during inspection. LPA and Staff completed the CARE tool together and found facility to be in substantial compliance.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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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