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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004258
Report Date: 09/26/2023
Date Signed: 09/26/2023 11:45:15 AM

Document Has Been Signed on 09/26/2023 11:45 AM - 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: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:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:THELMA CASUGAYTIME COMPLETED:
12:00 PM
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On 9/26/23 at approximately 9:15am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Thelma Casugay and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 4 bedrooms and 3 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 non ambulatory residents.

Facility Observation: Upon entry the residents were at day program. LPA observed a nearly completed puzzle on a table with other puzzles on a shelf. Games and art supplies were available. An electric keyboard was observed which administrator said was used for afternoon music.

During this inspection 6 of 6 resident files and 2 staffing files were reviewed for regulatory compliance. Staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances..
Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Water temperature in common bathroom reads 112*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 75*F. LPA observed the facility to have adequate food supply. .
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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: JO BIGORNIA HOME II
FACILITY NUMBER: 347004258
VISIT DATE: 09/26/2023
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Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 1/9/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. Facility conducts quarterly fire drills.

LPA requested an updated copy of LIC 308, LIC 309, LIC402, LIC610E and LIC 500, to be emailed to Jennifer.Fain@dss.ca.gov

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Thelma Casugay

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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