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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 03:29:32 PM

Document Has Been Signed on 10/25/2023 03:29 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Cherry MadambaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived on a subsequent visit on 10/25/23 at 11:30am. This visit to obtain additional information regarding an Special Incident Report submitted to Community Care Licensing (CCL) on 10/5/23.

On 10/4/23, Resident #1 (R1) sustained a fracture on the big toe on the left and fracture on the little toe on the right. Staff #1, noticed R1 was not doing normal routine in the morning. Administrator instructed staff to take R1 to the Urgent Care who supplied acetaminophen and ibuprofen in case there was any pain.

The facility opted to return R1 for xray at the Emergency Room the following day. The xray result was the fractures, which a boot was supplied by the ER and on the discharge documents states that R1 can return to program. The Primary Care Physician was seen on 10/11/23, who gave an orthopedic referral along with order to get vitamin D blood levels and suggested no weight bearing.

Regional Center conducted a visit on 10/6/23 and found resident in the normal daily demeanor (active). R1 has not presented to anyone as being in pain. The next appointment is 10/30/23 with the Orthopaedic.

Based on interviews, there is not a preponderance of evidence that the facility is at fault.

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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