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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003247
Report Date: 03/13/2024
Date Signed: 03/13/2024 01:15:56 PM


Document Has Been Signed on 03/13/2024 01:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:EMILY'S GUEST HOMEFACILITY NUMBER:
347003247
ADMINISTRATOR:TINTAS, MARIAFACILITY TYPE:
740
ADDRESS:7437 KANAI AVENUETELEPHONE:
(916) 745-3711
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 1DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator- Maria TintasTIME COMPLETED:
01:20 PM
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On 03/13/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Maria Tintas. and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to four (4) resident bedrooms, one (1) bathroom, kitchen, common areas, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 108.2 degrees Fahrenheit at the bathroom sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 73 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in the hallway next to kitchen, which was last inspected on 01/07/24. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of one (1) personnel and one (1) residents records. All records have the required documents.
Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for one (1) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR).

No deficiencies are being cited during today's inspection.

Exit interview conducted and copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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