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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003576
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:42:02 PM

Document Has Been Signed on 07/13/2023 01:42 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:VERGIE RAMOS HOME II, THEFACILITY NUMBER:
347003576
ADMINISTRATOR:RAMOS, VERGIEFACILITY TYPE:
735
ADDRESS:9424 TIMBER RIVER WAYTELEPHONE:
(916) 478-1340
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Consuelo SolomanTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual visit. LPA met with facility staff, and explained the purpose of the visit. Administrator Vergie Ramos came to the facility shortly after.

LPA and facility staff toured the facility to ensure compliance of Title 22 regulations. LPA observed 3 resident bedrooms, 2 bathrooms, common areas, kitchen, dinning room, laundry room, garage, and exterior area. Resident bedrooms were observed to be clean and organized. Bathrooms were clean and observed to have soap, hand sanitizer lotion, paper towels, trash cans, and hand rails.

LPA observed the temperature inside the facility was measured at 76*F. The hot water was measured at 107.8*F, which is within the regulatory range of 105 degrees F - 120 degrees F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of food and water was observed. LPA observed the centrally stored medications area, sharps, and chemicals to be locked and inaccessible to clients. LPA Valerio observed fire extinguisher(s) with last check on 05/13/2023, smoke and carbon monoxide detectors, and central heating and air in the facility.

Residents were observed to be away from the facility at their day program for the day. LPA reviewed staff and resident files. All 5 resident files were completed and up to date. All staff files reviewed had necessary training and completed files.

LPA reviewed the following documentation: LIC 500, LIC 308, LIC 610D, Surety Bond

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, and copy of report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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