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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004519
Report Date: 08/04/2023
Date Signed: 08/04/2023 11:19:32 AM

Document Has Been Signed on 08/04/2023 11:19 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: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:
08/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Monica Butay TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA met with facility staff and Administrator Monica Butay to ensure the facility is in compliance with applicable statutes and regulations.

During the visit, the LPA conducted interviews with staff. Based on interviews, staff receive pay checks bi-weekly, never receive a late pay check, have waived breaks, and are currently not approved to work any overtime. There is not any live-in care staff at the home. LPA observed two staff working at the facility and 2 residents in the facility. The other 2 residents went to Day Program. LPA reviewed staff files and resident files.

LPA conducted a tour of the physical plant and observed the facility to be within compliance with Title 22 regulations. Resident rooms has necessary furniture and furnishings. Bathrooms were fully stocked with toilet paper, paper towels, soap, and a trash can. The facility had a food supply enough for 7 days of perishables and 2 days of non-perishables. An emergency supply of food was observed. According to Administrator, there is some water damage in the corner or the door leading towards the back exit. The licensee plans to tell the owners of the home so they can get it fixed.

Based on interviews, file review, and observation of the physical plant, it appears the facility is within compliance with applicable statues and regulations. An exit interview was held with Administrator Monica, and a copy of the report was provided to Administrator Monica.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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