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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004519
Report Date: 04/11/2022
Date Signed: 04/11/2022 02:16:34 PM

Document Has Been Signed on 04/11/2022 02:16 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:PEER HOME #1FACILITY NUMBER:
347004519
ADMINISTRATOR:CUPINO, RAULFACILITY TYPE:
735
ADDRESS:9560 CASTLECAVE WAYTELEPHONE:
(916) 585-9103
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Monica Butay - AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection Visit. LPA met with Administrator and discussed purpose of visit.
Current census was 4 residents.
LPA conducted a tour of facility and observed physical plant with Administrator. Fire extinguisher expires 10/12/2 and annually inspected by River City Fire.
Kitchen area was toured. Drawers and cabinets were reviewed to make sure that they were functional and in compliance at this time. Chemicals, cleaning agents, and detergents were observed to be locked and made inaccessible to the residents at this time. Medications were locked and stored in a cabinet in the kitchen. Food supply was reviewed for adequate 2-day supply and 7-day nonperishable quantities.
Commons rooms were toured. Living room, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the resident bedrooms and restrooms was conducted. Bedroom furnishings and furniture were observed to be functional and maintained in compliance at this time.
Resident restrooms (2) were reviewed. Hot water temperature measured at 109.2 which in within the allowed range of 105-120 degrees.
Laundry area was reviewed and detergents, cleaning agents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Garage area was toured and observed to have been updated as an activity room for the residents.
Exterior grounds were toured. Side gate, perimeter fence, and all exits were observed to be functional and in compliance at this time. Tool shed in backyard was unlocked with six gallons of paint inside. Staff locked shed up immediately to keep chemicals inaccessible to clients.
A review of (4) of (4) resident files was conducted.
A review of (3) personnel records was conducted.
Per California Code of Regulations, Title 22, the following deficiency was observed during this visit. Exit interview was held with Administrator. A copy of reports and appeal rights left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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Document Has Been Signed on 04/11/2022 02:16 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/11/2022 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEER HOME #1
FACILITY NUMBER: 347004519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in shed in backyard was unlocked with 6 gallons of paint which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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Licensee agreed to lock shed up immediately to store chemicals which are inaccessible to clients. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022


LIC809 (FAS) - (06/04)
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