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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002723
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:40:03 AM

Document Has Been Signed on 10/18/2022 11:40 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:CHERRY MADAMBA'S RESIDENTIAL FACILITY INC. IIIFACILITY NUMBER:
347002723
ADMINISTRATOR:MADAMBA,CHERRY S.FACILITY TYPE:
735
ADDRESS:8429 ENZO WAYTELEPHONE:
(916) 525-1941
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Cherry Madamba - AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA was greeted by staff and LPA explained purpose of visit.

LPA and administrator toured both indoor and outdoors of facility. LPA observed the physical plant, food service, medications, client and staff records. The outside of the facility was observed to be in good repair and safe for residents. The inside of the facility was observed to be in good repair. Bathrooms and showers were clean and in good repair. The hot water temperature was measured 107.3*F which is within the required range of 105-120*F. Facility was maintained at a comfortable temperature. Required amounts of stored and perishable foods were present. Bedrooms were observed to be in good repair and bedding, storage and lighting were adequate. Medications, chemicals, and toxins were appropriately under lock and key. Smoke detectors were tested and operational. Facility is equipped with a central pull fire alarm. Fire extinguisher was fully charged and inspected on 10/26/2021. First aid kit was fully stocked for use. Facility license was openly posted for viewing. Administrator’s Certificate expires 6/29/2023.

Two (2) staff and two (2) resident’s records were reviewed. Staff have current First Aid/CPR certificates. A review of staff records indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

Exit interview held with administrator and a copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
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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