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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004469
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:09:19 PM

Document Has Been Signed on 03/18/2024 04:09 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: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: 4DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Zenaida AbriamTIME COMPLETED:
04:15 PM
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On 3/18/24, at 2:40pm, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced a annual visit. LPA initially met with the staff on duty and explained the purpose of today’s visit. The Administrator, Zenaida Abriam, was made aware of the visit and arrived shortly after. Present during this visit, there were 4 client in care with 3 staff on duty.

At 2:50pm, LPA and staff on duty inspected the facility’s 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. The facility is a one-story structure located in a residential neighborhood. No bodies of water were observed. Outside of the facility was observed to be cleaned and clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and area for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed inside the shed located at the backyard and contain to have gardening tools. LPA observed the shed to not have locked. Staff on duty was unable to properly locate the shut off valves (water, gas and electric) during the facility observation. LPA observed 5 client bedrooms and 3 bathrooms for client use. One bedroom is unoccupied at this time. One bedroom (bedroom #2) is a shared bedroom and currently being occupied by two clients in care. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathrooms were operational and adequately supplied.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. LPA observed inside the kitchen fridge and freezers and unable to determine if proper temperatures were maintained as per regulation. LPA provided technical assistance for licensee to ensure regulatory temperatures of the fridge and freezers are maintained.

Con't LIC 809-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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 2
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: KUNZITE RESIDENTIAL INC.
FACILITY NUMBER: 347004469
VISIT DATE: 03/18/2024
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Con't from LIC 809

Through an observation inside the kitchen pantry, LPA observed Pledge sprays, Bona floor cleaner, Windex, Lysol spray and dish soap. Staff immediately removed the items out of the pantry per LPA's request and placed them inside a locked cabinet in the garage. Room temperature was maintained in the facility at 74 degrees F. Water temperature in one of the bathrooms was measured at 119 degrees F. Fire extinguisher was serviced on 4/11/23. Smoke detectors and carbon monoxide were observed and found to be operable during this visit.

Medication storage area (located inside the pantry) was observed to be locked and inaccessible to clients in care. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for client use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of client in care.

During today's visit, deficiencies were observed:

  • Through an observation inside the kitchen pantry, LPA observed the following chemicals mixed with the food supplies: Pledge sprays, Bona floor cleaner, Windex sprays, Lysol sprays and dish soap. Staff immediately removed the items out of the pantry per LPA's request and staff placed them inside a locked cabinet in the garage.
  • Through an observation of the shed located in the backyard, LPA observed the shed to be without lock and LPA observed gardening tools and other materials inside the shed.

Due to time constraint, LPA Villanueva will return to this facility to complete this annual visit and issue citations that were observed from today's visit. An exit interview was held with Zenaida Abriam, Administrator/Licensee and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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