<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004258
Report Date: 09/29/2022
Date Signed: 09/29/2022 05:40:49 PM

Document Has Been Signed on 09/29/2022 05:40 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:JO BIGORNIA HOME IIFACILITY NUMBER:
347004258
ADMINISTRATOR:THELMA CASUGAYFACILITY TYPE:
735
ADDRESS:8607 ELK RIDGE WAYTELEPHONE:
(916) 714-5532
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Thelma CasugayTIME COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA met with facility staff, and explained the purpose of the visit. Administrator Thelma Casugay arrived to the facility shortly after LPA's arrival.

LPA and Administrator Thelma toured the physical plant to ensure compliance with title 22 regulations. An infection control tool was completed. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. Temperature inside the home was 78 degrees F. Emergency exits were clear from obstructions. LPA measured the water temperature at 109.0 degrees F, which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers, smoke and carbon monoxide detectors were observed in working condition with last check on 01/14/2022.  A first aid kit was observed to have necessary items LPA observed centrally stored medications, toxins, and sharps kept locked and inaccessible to clients. LPA observed the facility to have hand washing signs and COVID - 19 informational signs posted throughout the facility. The facility infection control plan and infection control plan for monkey pox was reviewed at the facility and met department requirements. LPA Valerio reviewed staff files for staff on shift. Training were up to date and up to date CPR/first aid was observed.

LPA obtained the following documentation: Infection Control Plan/Monkey Pox Control Plan and Updated Administrator Certificate. LPA requested the following documents be sent to the RO for facility file: LIC 308 Designation of Facility Responsibility, LIC 610E Emergency Disaster Plan, Surety Bond

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted with Administrator Thelma Casugay, and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1