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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001442
Report Date: 02/26/2024
Date Signed: 02/26/2024 03:42:21 PM

Document Has Been Signed on 02/26/2024 03:42 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ELK GROVE ADULT COMMUNITY TRAINING,INC. ACT IIFACILITY NUMBER:
347001442
ADMINISTRATOR:JAQUEZ, JOEFACILITY TYPE:
775
ADDRESS:9510 ELK GROVE FLORIN RD.,#CTELEPHONE:
(916) 685-7666
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 90CENSUS: 62DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Augusta Osayande, Program DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a required - 1 year visit on 2/26/23 at 10:30am and met with Augusta Osayande, Program Director and Stephanie Stanley, Site Coordinator and stated the purpose of the visit. The facility is licensed for a capacity of 90 clients of which 30 maybe non-ambulatory. LPA observed the LIC308 posted during this visit. Licensee fees are current.

LPA and Augusta Osayande, Program Director and Stephanie Stanley, Site Coordinator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are clients participating in activities during this visit. LPA observed the kitchen area, activity areas, bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps areas to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 110.2*F which is within the required range of 105-120*F. The temperature inside the facility measured between 69-72*F in all classrooms which is within the required range of 68-85*F.
LPA observed P&I monies for R1 which was not commingled and documented.
LPA observed clients bring their own meals and snacks on a daily basis which is not provided by the facility.
As part of the curriculum the facility staff conducts basic life skill classes where the items that are prepared by the clients are consumed by the clients and staff.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility.

LPA observed 3 client and 3 staff files during this visit. Facility has central heating and air and pull alarm system. LPA observed area where the resident files are locked and readily available for review.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELK GROVE ADULT COMMUNITY TRAINING,INC. ACT II
FACILITY NUMBER: 347001442
VISIT DATE: 02/26/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-Submit
Surety Bond LIC402-Submit
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-NA
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-Current
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-NA
Liability Insurance-(if applicable) Submit

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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