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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001571
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:36:52 PM

Document Has Been Signed on 09/28/2023 12:36 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:RICHBOROUGH FOUNTAIN, INC.FACILITY NUMBER:
347001571
ADMINISTRATOR:SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:9038 RICHBOROUGH WAYTELEPHONE:
(916) 685-1194
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Josephine ShobhnaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Christina Valerio and Policy Analyst (PA) Melody Bradley arrived to the facility unannounced to conduct an annual required inspection. LPA met with facility staff and explained the purpose of the visit. LPA was later met by Co-Administrator Josephine Shobhna.

LPA Valerio, PA Bradley, and Administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 3 resident bedrooms, which were observed to be fully furnished, organized, and free from odors. LPA observed a shared resident bathroom. Hot water was measured at 111.2*degrees F. Resident bathrooms had toilet paper, paper towels, soap, hand sanitizer, and a trash can. Common areas were observed to be furnished and free from odors. Technical Assistance was provided for the use of ceiling fans. The facility temperature thermometer showed a reading of 77*degrees F. Medications, sharps, and cleaning supplies were observed to be locked and inaccessible to residents in care. The kitchen was observed to be clean, had a food supply to meet Title 22 requirements, and was observed to have an emergency supply of canned food items. The garage area is locked and inaccessible to residents. This area had extra food supplies, cleaning supplies, PPE supplies, and the washer and dryer. The backyard was observed to have an area for sitting and emergency walk ways were clear. The facility has a pull alarm fire alarm and multiple fire extinguishers with last inspection on 05/31/23.

LPA reviewed staff and resident files. LPA interviewed staff and residents during the visit. Residents were observed watching television and sitting on the couch. Staff were observed assisting residents, cleaning, and filling out medication paperwork.

LPA requested the following documentation: LIC 500, LIC 308, Surety Bond, and LIC 610

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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