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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003894
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:03:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/22/2025 03:03 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:ELENA'S CARE HOMEFACILITY NUMBER:
347003894
ADMINISTRATOR/
DIRECTOR:
ROZPADNYUK, ELENAFACILITY TYPE:
735
ADDRESS:6800 CASA DEL ESTE WAYTELEPHONE:
(916) 379-9828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Lana Makovsky, Direct Service ProviderTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 01/22/2025.  LPA Campbell met with Lana Makovsky, Direct Service Provider (DSP), and explained the purpose of the visit. Lana Makovsky, assisted with today’s visit.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (4) ambulatory residents, one (1) of which may be non-ambulatory.  LPA Campbell observed the facility to be free of odor and in good repair. The banquette dining area in the kitchen area was observed to have crumbs on the seating and in the crevices. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured in the bathroom. The resident bathroom water temperature measured at 120 degrees. Fire extinguishers, smoke and carbon monoxide detectors were tested and are in good repair. Facility thermostat observed at 72 degrees Fahrenheit.(F). LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients in the staff room. The First aid kit was complete and contained bandages, scissors, thermometer, tweezers and a manual for first aid and cpr. LPA Campbell requested client and staff files for review.

LPA reviewed 4 resident files and 5 staff files. Resident files were found to be complete. Staff files were also found to be complete with fingerprint clearance. Toxins were made inaccessible to clients in care and were stored in the garage.
Lisa RiosTELEPHONE: (916) 969-9685
Renee CampbellTELEPHONE: (916) 206-6380
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELENA'S CARE HOME
FACILITY NUMBER: 347003894
VISIT DATE: 01/22/2025
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It is suggested that the hire date be placed with the staff name on the front of their binders for ease of locating and that staff be trained on how to test the smoke and carbon monoxide alarms.

The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 10/04/2023 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate   
(4) LIC 610 Emergency Disaster Plan

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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