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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003636
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:00:49 PM


Document Has Been Signed on 05/24/2022 04:00 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:MIRALEX ELDERLY CARE HOMEFACILITY NUMBER:
347003636
ADMINISTRATOR:MCMAHON, NANCY MAEFACILITY TYPE:
740
ADDRESS:8376 DANDELION DRIVETELEPHONE:
(916) 896-0720
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Nancy McMahonTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual visit. LPA Valerio confirmed with Administrator that there are zero residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. The infection control domain tool was completed during the visit. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. The facility was observed to be clean and organized. The facility has a 30-day supply of PPE.

LPA observed the temperature inside the facility was measured at 77*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 106.2*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Facility has an emergency supply of food. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. 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 extinguisher was up to date with last check on 01/25/2022.

Prior to the visit, the licensee sent LPA liability insurance updated on 03/02/2022, LIC 308, Emergency Disaster plan, and updated LIC 500.
 
Per California Code of Regulations, Title 22, Division 6, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with facility staff Nancy McMahon.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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