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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003844
Report Date: 11/23/2022
Date Signed: 11/23/2022 04:24:44 PM

Document Has Been Signed on 11/23/2022 04:24 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:CRUZ HOMEFACILITY NUMBER:
347003844
ADMINISTRATOR:JAMES NWABEKEFACILITY TYPE:
735
ADDRESS:9004 MOSELY CTTELEPHONE:
(916) 525-1423
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
11/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Bernardo Cruz, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Renee Campbell arrived at facility at approximately 9:55 am to conduct an unannounced Quarterly Required visit on this date. LPA was met by staff1 (S1) and toured the facility with Licensee, Bernardo Cruz when he arrived along with acting Administrator Lillia League at 10 am. Licensee Bernardo Cruz currently holds a certificate (#6016809735) that expires on 08/20/2024. The facility’s fire clearance was approved on 08/06/2007.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. The hot water temperature is maintained at 114 degrees Fahrenheit. All outdoor and indoor passageways were kept free from obstruction. Rooms were furnished appropriately. There was an adequate supply of toiletries, hygiene supplies, and extra linens. LPA observed clients’ linens were in good repair. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Fire extinguishers, smoke detectors and carbon monoxide were checked. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the clients’ needs. All staff have criminal record clearance and are associated to the facility. LPA reviewed clients’ files and a sample of clients’ medication log were reviewed.

Additionally, LPA observed Administrator of Record to not be on site or listed on the LIC 500 upon review. Licensee’s Administrator of record is not adhering to Department requirements of Administrator presence of no less than 40 hours per week for purposes of care and supervision as stated in previous meetings and visits with Licensee since 9-22-22.

Citation is issued as a result of today's case management and noted on LIC 809D. A civil penalty in the amount of $250 is issued due to repeat violation. An exit interview was held with Bernard Cruz and a copy of this report was left with Bernard. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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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Document Has Been Signed on 11/23/2022 04:24 PM - It Cannot Be Edited


Created By: Renee Campbell On 11/23/2022 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CRUZ HOME
FACILITY NUMBER: 347003844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
85065(b)

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Personnel Requirements. (b)The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by:
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POC: Licensee and Administrator will read regulation 85065(b) and submit a signed statement of understanding to LPA by POC due date. Licensee will submit updated documents reflecting changes in Administrator coverage to LPA by POC due date including LIC200, LIC 500, LIC308, updated Administrator Certificate.
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Based on interview, licensee’s Administrator of record is not adhering to Department requirements of Administrator presence of no less than 40 hours per week for purposes of care and supervision. This poses a potential health and safety risk to residents in care. A civil penalty for repeat violation within 12-month period is issued in addition to citation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022


LIC809 (FAS) - (06/04)
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