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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004469
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:05:58 PM

Document Has Been Signed on 03/11/2022 12:05 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:KUNZITE RESIDENTIAL INC.FACILITY NUMBER:
347004469
ADMINISTRATOR:ABRIAM, ZENAIDAFACILITY TYPE:
735
ADDRESS:9646 KUNZITE COURTTELEPHONE:
(916) 897-8801
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Zenaida AbriamTIME COMPLETED:
12:11 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA Valerio confirmed with staff that there are 0 staff or residents that have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio met with Administrator Zenadia, whom put facility staff in charge for the duration of the visit and to sign the final report. The infection control domain tool was completed during the visit. LPA Valerio observed updated PINS, including most recent visitation guidelines, posted at the front door and entry way of the facility. Facility staff were observed wearing surgical mask. Staff stated all areas of the home are cleaned multiple times per day.

Facility Staff and LPA Valerio toured the physical plant to ensure compliance of Title 22 regulations. LPA observed the kitchen to have an emergency supply of food, a locked cabinet for sharps and cleaning supplies, a supply of perishable foods for seven days, and a supply of non-perishable food for a minimum of two days. Facility staff were observed to be cooking lunch while other residents were engaging in activities with staff. Resident rooms were furnished with required furniture and were clean and free from debris. Common areas are said to clean every shift and observed by LPA to be clean. Resident bathrooms were fully stocked with necessary items, including soap, hand sanitizer, paper towels, and a trash can with a lid. Emergency exits were free from obstructions. The fire extinguisher was fully charged with last check on 04/20/2021. The hot water was measured at 114.8*F, which is within the required range of 105*F - 120*F.

LPA Valerio requested the following documentation: LIC 500, LIC 308, Surety Bond, and LIC 610D

Per the California Code of Regulations, Title 22, Division 6,no deficiencies were observed or cited. Exit interview held, and a copy of the report was left at the facility for Administrator Zenaida Abriam
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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