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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002643
Report Date: 02/08/2022
Date Signed: 02/08/2022 10:48:27 AM

Document Has Been Signed on 02/08/2022 10:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JD PARAN GUEST HOMEFACILITY NUMBER:
347002643
ADMINISTRATOR:JINKY PARANFACILITY TYPE:
740
ADDRESS:9410 HOSPENTHAL WAYTELEPHONE:
(916) 686-4576
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator - Jinky ParanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Ruth Wallace, conducted an unannounced 1-year required infection control inspection. LPA met with Administrator Jinky Paran and explained the purpose of the visit. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had her temperature checked at facility.
LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, PPE, food and cleaning supply storage. Administrator Certificate expires 04/23/2023.
LPA conducted a tour of the facility with Administrator. The physical plant is consistent with the submitted facility floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. Facility refrigerator is stocked with meats, eggs, vegetables, milk, and fruit. The hot water was measured at 106.7*F in kitchen sink which is within regulatory range of not less than 105*F and not more than 120*F. Seven day non-perishable food supply and two day perishable food supply is sufficient. LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris.
The residents' bedrooms were inspected and all had the required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguisher expires 11/5/2022.. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked. Medication supply is also stored and locked. PPE supply is sufficient, as stated by the Administrator. Additional wipes and sanitizer are stored in the garage.
LPA reviewed three resident and found them to contain required paperwork and current physician reports; LPA compared ordered medications to those being administered for (2) residents and found no errors. Facility is correctly logging medications on the Centrally Stored Medication Record (LIC622).
LPA reviewed (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. LPA received current copies of LIC 308 Designation of Responsibility, LIC 500 Personnel Report, and current Liability Insurance which expires 8/15/22.
No deficiencies were cited today. Exit interview conducted with Administrator and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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