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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003576
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:44:06 AM

Document Has Been Signed on 07/11/2024 11:44 AM - 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:VERGIE RAMOS HOME II, THEFACILITY NUMBER:
347003576
ADMINISTRATOR/
DIRECTOR:
RAMOS, VERGIEFACILITY TYPE:
735
ADDRESS:9424 TIMBER RIVER WAYTELEPHONE:
(916) 478-1340
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Vergie RamosTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7/11/24 at 9:45pm Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a required annual visit. LPA initially met with facility staff, and stated the purpose of the visit. The Licensee/Administrator, Vergie Ramos, was notified of the visit and arrived shortly after. Today's visit, there were 2 clients in care with 2 staff on duty.

At 10am, LPA and staff on duty inspected the physical plant and environment of the facility. The facility is a two-story home located in a residential neighborhood consisting of 2 resident bedrooms upstairs and 1 resident bedroom downstairs. Facility has one full resident bathroom upstairs and one full resident bathroom downstairs. LPA observed common areas to be clean and free from debris and obstructions. All three resident bedrooms were observed to be shared and fully furnished and have enough space to accommodate resident belongings. Two bathrooms were observed to be well maintained and sanitized. Facility maintains an adequate amount of linen supplies. The room temperature was observed at 75 degrees F. Hot water temperature was taken in the downstairs bathroom was observed to be at 105 degrees F. The kitchen was observed to be clean and sanitary. Facility maintains regulatory temperature for the refrigerator and freezer. The facility maintains nonperishable foods for a minimum of 7 days and perishable food for 2 days. The garage houses additional freezer, washer and dryer. Two fire extinguishers are maintained in the facility and were observed to be fully charged and were last serviced on 5/8/24. Medications, cleaning supplies, and sharp objects were observed to be locked and inaccessible to clients in care. LPA conducted facility record review, 3 staff records review, and 5 client records review. All were observed to be in compliance at this time. Additionally, LPA conducted medication review and were observed to be in compliance. Facility handles clients money. LPA and a staff member counted 2 of 5 clients money and no issues were noted. Facility conducts a monthly disaster drill as evidenced by through record review. Smoke/carbon monoxide detectors were observed to be in each bedrooms and hallways and were tested and found to be operational. LPA observed activity supplies for residents.
LPA requested the following documentation to be emailed to LPA: LIC 500, LIC 308, Surety Bond, and liability insurance.
Per California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed during this visit. An exit interview was held with Vergie Ramos, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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