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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002442
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:03:07 PM

Document Has Been Signed on 12/28/2023 12:03 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELACRUZ HOME CAREFACILITY NUMBER:
347002442
ADMINISTRATOR:RUFO DELACRUZFACILITY TYPE:
735
ADDRESS:8100 ORCHID TREE WAYTELEPHONE:
(916) 332-9574
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
12/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator- Thelma DelacruzTIME COMPLETED:
12:05 PM
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On 12/28/23 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Talwinder Bains arrived at the facility unannounced to conduct a case management visit. LPAs met with the Administrator, Thelma Delacruz and explained the purpose of the visit.

The purpose of today's visit is to follow up on the Title 17 review conducted at this facility by Alta California Regional Center (ACRC) on 12/07/23. Facility Action Report (FAR) was generated by ACRC from the Title 17 reviews. Community Care Licensing Division (CCLD) received a copy of the FAR and it was noted in the FAR the facility was cited for violations that are for Title 17. The visit today is to address the issues found in the FAR that apply to Title 22.

LPAs and administrator discussed the importance of reporting any reportable incidents to CCLD. Administrator stated that during medication audit on 12/07/23 by ALTA staff, it was found out that facility was not documenting PRN medications in the Centrally Stored log as required. LPAs and administrator discussed the importance of logging in all PRN medications in the Centrally Stored log per Title 22 regulation. Administrator stated that facility is already working on plan of correction issued by ALTA and will train staff for medication administration per Title 22.

No citations were issued today, however Technical Advisory has been issued.

Exit interview conducted and copy of report was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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