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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002723
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:37:11 PM

Document Has Been Signed on 10/25/2023 02:37 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: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:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cherry MadambaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/25/23 at 11:30am. LPA met with Cherry Madamba and stated the purpose of the visit. The Administrator Certificate expired on 6/29/2023. LPA was presented with a copy of the ACS Applications Pending List which confirmed Administrator has submitted pertinent documents and payment prior to due date. Licensing fees are current. LPA observed a copy of the Liability Insurance with an aggregate of 3,000,000 which expires 6/1/2024. LPA observed documented and counted monies for resident #1 (R1) which was not commingled to be in the correct amount during this visit. The facility is licensed for a total capacity of 6 residents. Upon arrival some residents were at day program and 1 was present involved with their individual activities. Facility has a Restricted Health Conditions Care Plan and Infection Control Plan on file. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0 *F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. During the visit, the Fire Dept. arrived to service the fire extinguishers and LPA observed a test of the carbon monoxide detector. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 resident and 2 staff files and conducted interviews during this visit.

Upon a file review the following documents are discussed to be submitted annually with any changes: Personnel Report (LIC500), Designation of Administrative Responsibility (LIC308), Affidavit Regarding Client/Resident Cash resources (LIC400), Surety Bond (LIC402), Administrator Certificate-updated, Control of Property, Emergency Disaster Plan (LIC610E), Any addendums to the Infection Control Plan.
Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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