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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002442
Report Date: 08/22/2024
Date Signed: 08/22/2024 10:09:11 AM

Document Has Been Signed on 08/22/2024 10:09 AM - 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/
DIRECTOR:		RUFO DELACRUZFACILITY TYPE:
735
ADDRESS:8100 ORCHID TREE WAYTELEPHONE:
(916) 332-9574
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator- Thelma De Le CruzTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 08/22/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPA met with Administrator Thelma De La Cruz and explained the purpose of the visit.

LPA and administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: residents bedrooms, bathroom, kitchen, common areas and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 110 degrees Fahrenheit at the bathroom sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 76 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in the kitchen, which was last inspected on 06/28/2024. LPA reviewed drill logs, which are conducted monthly. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) resident files, which contains signed admission agreements, physician's reports, identification sheets, consent forms, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in medications, first aid/CPR, and other various areas.

No deficiencies being cited during today's inspection.

Exit interview conducted and copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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