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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003844
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:29:02 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: 6DATE:
01/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Bernardo CruzTIME COMPLETED:
02:28 PM
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On 1-25-22 at 1:45pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conducted a case management visit at Motel 6 located at 7407 Elsie Ave, Sacramento, CA. 95828. LPA met with Bernardo Cruz and explained the purpose of the visit. Currently there are 2 clients to 3 different rooms in #110, #220, and #224. Medication are locked and secured in a portable travel locker with pad lock and inaccessible to clients in care. Medication log book is secured in locker. One resident is currently with family. One client was returning from the hospital during today's visit, who was admitted to hospital earlier today.

Clients were watching TV. Adequate food supply and water in all three rooms was observed by LPA. One staff member is assigned to each room to supervise clients.

No deficiencies cited as a result of today's visit. An exit interview was conducted with Bernardo Cruz and a copy of this report was left with Bernardo.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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