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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003312
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:05:21 PM

Document Has Been Signed on 11/15/2024 12:05 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:JERIDA LANE RESIDENTIAL CAREFACILITY NUMBER:
347003312
ADMINISTRATOR/
DIRECTOR:		OLEA, ESTRELLITA M.FACILITY TYPE:
740
ADDRESS:8830 JERIDA LANETELEPHONE:
(916) 863-6151
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Estrellita OleaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility unannounced on 11/15/2024 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and three (3) bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 108.4 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPAs observed knives and disinfectants to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of debris and clutter. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. LPAs reviewed six (6) resident files and three (3) staff files. LPAs obtained a current copy of certificate of liability insurance.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview was conducted and a copy of the report was given at the conclusion of this visit.
Anthony PerezTELEPHONE: (323) 485-4915
Cassandra MikkelsonTELEPHONE: 916-709-6830
DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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