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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002908
Report Date: 06/28/2021
Date Signed: 06/28/2021 05:02:51 PM

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:REBECCA'S GUEST HOMEFACILITY NUMBER:
347002908
ADMINISTRATOR:MORRIS, REBECCA C.FACILITY TYPE:
740
ADDRESS:9458 HOSPENTHAL WAYTELEPHONE:
(916) 602-7482
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 2DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Administrator Rebecca Morris TIME COMPLETED:
03:52 PM
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On 06/28/21 at 2:57 PM, Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, met with Administrator Rebecca Morris Crisostomo, and explained the purpose of the visit. Additionally, LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.
 
LPA Valerio inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living room, staff room, and outside areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.
 
The facility does not have an approved LIC 808 mitigation plan on file. LPA Valerio and Administrator Rebecca reviewed the LIC 808 together and discussed what is needed for the plan to be approved. Administrator Rebecca stated she would send plan via e-mail within 48 hours. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have hand washing signs, COVID-19 informational signage posted at the front door and throughout the facility. The facility is able to designated and dedicated a Covid-19 bedroom and bathroom if needed.
 
Water temperature reads 109.1.°F in bathroom 1 and 106.7 °F in bathroom 2, within regulatory range of 105 *F and 120 *F. Room temperature reads 72° F. LPA observed the facility to have adequate food supply with an emergency food supply. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Medication cabinet was locked. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 11/04/2020.
 
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held, a copy of the report was given, and a copy was left with Administrator Rebecca Morris Crisostomo.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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