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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003844
Report Date: 01/23/2022
Date Signed: 01/23/2022 03:13:16 PM

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:CRUZ, CAROL/BENARDFACILITY TYPE:
735
ADDRESS:9004 MOSELY CTTELEPHONE:
(916) 525-1423
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
01/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Brian CruzTIME COMPLETED:
02:49 PM
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LPA Albert Johnson made an unannounced visit on this date to complete a health and safety check at the Motel 6 at 7407 Elsie Ave. Sacramento, CA 95828

The residents are located in rooms 110, 220 and 224. There is assigned staff for each room and in each room there are two residents. R1 is still out on a home visit. The remaining five
were alert and well.

LPA observed the residents in each room they were watching T. V. with staff. The residents appear to be safe. There is water, food and snacks in each room. The medications are locked in room 224 in a travel locker that has a pad lock on it. LPA reviewed the medication administration record and confirmed that medications are being given as ordered. The residents' book are also locked in the footlocker as well.

No deficiencies cited.

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2022
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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