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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004287
Report Date: 01/05/2024
Date Signed: 01/05/2024 09:53:51 AM

Document Has Been Signed on 01/05/2024 09:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ULEP'S RESIDENTIAL FACILITYFACILITY NUMBER:
347004287
ADMINISTRATOR:ULEP, AQUILINAFACILITY TYPE:
735
ADDRESS:8609 MARMON WAYTELEPHONE:
(916) 689-8509
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:AQUILINA ULEP - ADMINISTRATORTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with Administrator and explained purpose of visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in kitchen sink at 112.3 degrees Fahrenheit which is within the required range of 105 to 120 degrees.
Fire extinguishers last inspected on 8/14/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 12/30/2023.

LPA reviewed three client files and two staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents will be submitted via email to LPA Wallace by 1/19/2024:
LIC 308 Designation of Administrative Responsibility, LIC 400 Client/Resident Cash Resources, LIC 500 Personnel Report, LIC 999 Facility Sketch, Administrator Certificate, and Proof of Current Surety Bond with Expiration Date.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit.
Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) were left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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