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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000981
Report Date: 01/21/2022
Date Signed: 01/24/2022 04:14:51 PM

Document Has Been Signed on 01/24/2022 04:14 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CARING FAMILIES-BV1FACILITY NUMBER:
347000981
ADMINISTRATOR:MACIAS, MICHELLEFACILITY TYPE:
740
ADDRESS:8712 BRAY VISTA WAYTELEPHONE:
(916) 685-0404
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/21/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michelle Macias, Facility AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual Inspection. Facility Administrator Michelle Macias was informed of the purpose of the visit and was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a written mitigation plan (LIC 808) and LPA reviewed and discussed the plan and current Licensing guidance..

LPA toured the facility and reviewed the Mitigation Plan as well as discussing COVID Training Procedures during the Inspection. Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced in February 2021 and are in compliance and are due to be serviced next month. Facility has carbon monoxide detectors. Medication were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were observed and determined to be adequate for a 30 supply.

The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are six clients in the home and five client bedrooms, two clients are on hospice. LPA observed this facility to have a locked perimeter. This facility has a locked perimeter waiver on file.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CARING FAMILIES-BV1
FACILITY NUMBER: 347000981
VISIT DATE: 01/21/2022
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LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs. Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Current LIC 500, LIC 308, and LIC 309 were submitted to Licensing within the last year

Exit interview held with Michelle Macias, no deficiencies were identified and a copy of report given at the conclusion of the visit
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
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