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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003507
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:03:40 PM


Document Has Been Signed on 10/01/2024 04:03 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:VICIO CARE HOMEFACILITY NUMBER:
347003507
ADMINISTRATOR:VICIO, LEA M.FACILITY TYPE:
740
ADDRESS:9063 WHARTON WAYTELEPHONE:
(916) 689-8012
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lea VicioTIME COMPLETED:
04:00 PM
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On 10/1/24, at 1:15pm Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct an annual required visit. LPA met with staff on duty, Leana Vicio (S1), and explained the purpose of the visit. The Administrator, Lea Vicio, was notified of the visit and arrived shortly after.

LPA and S1 toured the facility to ensure compliance with Title 22 regulations. LPA observed 4 resident bedrooms, 2 bathrooms, common areas, and dinning area. Bedrooms were furnished, clean, and free from debris. Bathrooms were fully stocked with paper towels, soap, trash cans, handrails, and hand sanitizer. Medication, cleaning supplies, and sharps were observed to locked and inaccessible to residents in care. Facility temperature was observed to be 75*F. Hot water in the one bathroom was measured at 119.8*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. No emergency exits were obstructed. The backyard was observed to be free from debris and had an area for outdoor activities. Kitchen was observed to be sanitary. Kitchen refrigerator and freezer was observed to be large to store food supply. Technical Assistance (TA) was provided for licensee to obtain thermometer for the refrigerator and freezer. Upon arrival, one resident in care was present with one staff on duty. Later during the visit, the rest of the residents in care arrived from the community and a second staff also arrived later.
LPA spoke to residents and staff during the visit. LPA reviewed 4 staff files and 3 of 6 resident files. Staff files were observed to be in compliance at this time with current 1st Aid/CPR certificate and background clearance. Based on 3 resident record review, LPA observed 2 of 3 resident file do not contain PRN Authorization Letter. TA was provided to licensee to obtain PRN Authorization from residents' physicians. LPA reviewed facility infection control plan and emergency procedure plan.
LPA obtained copy of the following documentation during this visit: LIC 500, LIC 308, Liability Insurance, Surety Bond.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. An exit interview was held with Administrator Lea, and a report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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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