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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003636
Report Date: 06/23/2021
Date Signed: 06/27/2021 09:54:58 PM

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:MIRALEX ELDERLY CARE HOMEFACILITY NUMBER:
347003636
ADMINISTRATOR:MCMAHON, NANCY MAEFACILITY TYPE:
740
ADDRESS:8376 DANDELION DRIVETELEPHONE:
(916) 667-9519
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 2DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Nancy McMahonTIME COMPLETED:
02:20 PM
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On 06/23/21 at 1:40 PM, Licensing Program Analysts (LPA) Christina Valerio and LPA Suong Teh arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced themselves, met with Administrator Nancy McMahon, and explained the purpose of the visit. Additionally, LPA Valerio and LPA Teh was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.

LPA Valerio and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living room, and garage of the facility to ensure compliance with Title 22 regulations. Emergency exits are free from obstruction. LPA also conducted the infection control domain tool.

The facility has an approved LIC 808 mitigation plan on file. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have PINS, COVID-19 Informational, and hand washing signs posted throughout the facility. The facility is able to designated and dedicated a COVID-19 bedroom and bathroom if needed. 

Water temperature reads 105° F, within regulatory range of 105 *F and 120 *F. Room temperature reads 68° F. LPA observed the facility to have adequate food supply. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 01/14/2021. Medications cabinet was locked.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a copy of the report was given with Administrator Nancy McMahon.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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