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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003296
Report Date: 10/20/2022
Date Signed: 10/20/2022 12:59:19 PM


Document Has Been Signed on 10/20/2022 12:59 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:JD PARAN GUEST HOME IIFACILITY NUMBER:
347003296
ADMINISTRATOR:PARAN, JINKYFACILITY TYPE:
740
ADDRESS:9458 NEWINGTON WAYTELEPHONE:
(916) 684-5959
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Zinky Paran - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA explained purpose of visit with Administrator. Administrator Certificate #: 6001968740, Exp: 04/23/2023). There are currently 4 residents who reside at this facility. There are no residents who have restricted health care conditions and no residents who are currently receiving wound care. This facility has a hospice wavier for four (4) and currently has two (2) residents on Hospice.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2 day perishable and 7 day nonperishable. Smoke alarms were checked and in good working order. LPA observed an adequate amount of linens. Hot water temperature measures at 110.3 degrees F. This facility is operating within the scope of their license. LPA observed the fire extinguisher(s) which were inspected on 11/2/22, smoke and carbon monoxide detector(s) in the home. Last fire drill conducted 7/24/22.

LPA reviewed two (2) resident and two (2) staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

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 to administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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