<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003636
Report Date: 05/27/2023
Date Signed: 05/27/2023 12:43:39 PM


Document Has Been Signed on 05/27/2023 12:43 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:
05/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Nancy McMahonTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to the facility to conduct an annual/required visit. LPA Lund explained the reason for the visit to Administrator Nancy McMahon. Census 3

LPA Lund & Administrator Nancy McMahon toured/inspected the physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. LPA observed the temperature inside the facility was measured at 76*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 107*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. The facility has 7-days nonperishable foods and fresh perishable foods for a minimum of 2- days. The 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 are sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. The fire extinguisher was inspected on 01/17/2023. LPA Lund reviewed 2 staff and 2 residents files. LPA observed liability insurance updated on 03/09/2023, 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 Administrator Nancy McMahon.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1