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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001851
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:21:34 PM

Document Has Been Signed on 10/12/2022 02:21 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:ELK GROVE ADULT COMMUNITY TRAINING/GALT I & IIFACILITY NUMBER:
347001851
ADMINISTRATOR:BRUBAKER, REBECCAFACILITY TYPE:
775
ADDRESS:1067 C STREET, SUITE 116TELEPHONE:
(916) 685-7666
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 61CENSUS: 19DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gary Keisler, Program Coordinator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at this facility unannounced to conduct an annual/required inspection visit. LPA met with Gary Keisler, Program Coordinator and explained the purpose of the visit. Census 19

LPA Lund toured/inspected the physical plant including but not limited to the kitchen area, classroom/activity area, bathrooms, laundry room, and conference room of the facility to ensure compliance.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area for both Act I and Act II. The facility conducts routine symptom screening for employees, clients, and visitors. COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area. The facility has a designated infection control lead for both Act I and Act II. The facility is able to designate and dedicated a Covid-19 room/bathroom area if needed at both sites. Common touch surfaces are cleaned after each use. No sharp objects or toxins accessible to clients.

LPA Lund observed the activity area was sanitary and had the required furniture and furnishings. Medications were locked and secured. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 5/24/22 and fully charged for both Act 1 and Act II. Fire drills are conducted every other month.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Gary Keisler, Program Coordinator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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