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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004519
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:16:38 PM

Document Has Been Signed on 05/23/2023 04:16 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PEER HOME #1FACILITY NUMBER:
347004519
ADMINISTRATOR:BUTAY, MONICAFACILITY TYPE:
735
ADDRESS:9560 CASTLECAVE WAYTELEPHONE:
(916) 585-9103
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Monica ButayTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with administrator Monica Butay and explained the purpose of the visit.

LPA Moleski reviewed two resident files (R1-R2) and five staff files (S1-S5).

LPA Moleski toured the facility with Butay and inspected common areas, the kitchen, bedrooms, bathroom, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility's temperature was 75 degrees Fahrenheit, which is within the required 68 and 85 degree range.

LPA Moleski observed a first aid kit, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked closet for the storage of cleaning solutions. LPA Moleski observed a locked cabinet for the storage of knives.

LPA Moleski interviewed R1, R2, S2, and S3.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Butay.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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