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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003636
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:41:19 PM


Document Has Been Signed on 05/31/2024 04:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Nancy McMahonTIME COMPLETED:
04:45 PM
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On 5/31/24 at 3:12pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual inspection. LPA met with the facility administrator, Nancy McMahon and explained the purpose of the visit. Present during today's visit were 3 residents in care with 2 staff on duty.
At 3:30pm, LPA and Administrator conducted a physical inspection of the facility. This is a two-story home located in a residential neighborhood. Note that the first floor is for resident use and the second floor is for staff use. During the tour outside, LPA observed the front and backyard to be clean and free of obstruction. The side gate was observed to be operational and contain a code-compliant self-locking latch. Fences are in good repair at this time. LPA observed a covered patio with outdoor furniture for resident use. The facility does not have bodies of water at this time.
During the tour inside the facility, LPA observed 3 resident bedrooms and 1 bathroom for resident use. Two of the bedrooms were observed to be single room. The shared bedroom currently has one resident. Each of the bedrooms were observed to be furnished with required furniture and storage were observed to be spacious for residents' belongings. Each bedrooms were observed to have smoke detectors. Smoke detectors were tested and operational. Facility has 2 carbon monoxide detectors. Facility maintains a room temperature at 79 degree F. Fireplace was observed to be screened. Bathroom was observed to be sanitized and and free of clutter. During the inspection of the bathroom, LPA observed the trash can to not contain a lid. Additionally, the bathroom was observed to be equipped with grab bars and non-skid shower mat. Hot water temperature was taken in the bathroom faucet and measured at 108 degrees F.
Inspection of the kitchen was observed to be clean and sanitized. Food supplies were observed to be properly stored. Kitchen refrigerator was observed at 38 degrees F and kitchen freezer was observed to be at 0 degrees F. The facility maintains 2-day perishable and 7 day non-perishable food supplies. Cleaning supplies and other toxic products were found to be locked in the laundry room and inaccessible to residents in care. Sharps objects and medications were observed to be locked in the kitchen area and inaccessible to residents in care.
Due to insufficient time, the Department will return at a later date to conduct annual continuation visit. An exit interview was conducted with Nancy McMahon and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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