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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003636
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:35:21 PM


Document Has Been Signed on 06/04/2024 03:35 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:
06/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Nancy McMahonTIME COMPLETED:
03:40 PM
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On 6/4/24 at 1:12pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct an annual continuation visit to continue the annual inspection initiated on 5/31/24. LPA met with the designated staff and explained the purpose of the visit. The administrator was notified of the visit and arrived shortly after her appointment. Present during today's visit were 3 residents in care with 1 staff on duty.

During this inspection, LPA conducted an audit of facility files, 3 resident files, and 2) staff files for regulatory compliance. All 2 staff have criminal background clearances and are associated to this facility. All 2 staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required training. During resident file review and medication review, LPA discovered that 2 of 3 residents have PRN medications but did not have in their files PRN authorization letters signed by their physicians. Technical assistance was provided to the administrator to obtain a signed copy of PRN Authorization letter for each resident requiring PRN medications. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy for 3 residents. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. First aid kit was observed to have adequate supplies and accessible to staff.

Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Per interview with the administrator, facility staff conduct quarterly fire drill but do not document it. LPA provided a technical assistance for the administrator to start documenting their quarterly fire drills. LPA was provided updated copy of LIC 308, LIC 500, 1 and liability insurance.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Administrator Nancy McMahon, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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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