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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001680
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:19:25 PM

Document Has Been Signed on 11/15/2023 04:19 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 SPRING HOMES INC.FACILITY NUMBER:
347001680
ADMINISTRATOR:TEJADA, CARMENCHITAFACILITY TYPE:
735
ADDRESS:8720 SECKEL CT.TELEPHONE:
(916) 686-5547
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Clifford G. TejadaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/15/23 at 1:30PM to conduct a Required - 1 Year inspection visit. LPA met with Deirdre Pinheiro, Caregiver, Clifford G. Tejada, Administrator, Carmenchita Tejada, Licensee and explained the purpose of the visit. Licensing fees are current. The Administrator certificate for Clifford G. Tejada expired 6/3/23 but LPA observed documentation that the renewal has been submitted with fees to Community Care Licensing.(CCL) timely.
The facility is licensed for a capacity of 6 residents. LPA observed residents are at day program during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the facility is handling P&I monies for residents which are not commingled. P&I for resident #1 (R1) is documented and counted as exact and correct during this visit. Facility has a Infection Control Plan on file. The temperature inside the facility was observed to be at 69*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.9*F which is within the required range of 105-120*F. LPA observed a pull alarm system with sensors, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610E), any addendums or updates to Infection Control Plan.
Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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