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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004525
Report Date: 03/29/2024
Date Signed: 03/29/2024 04:43:18 PM

Document Has Been Signed on 03/29/2024 04:43 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:EMBASSY FOUNTAIN INC. #2FACILITY NUMBER:
347004525
ADMINISTRATOR:NITTA, LEILANI M.FACILITY TYPE:
735
ADDRESS:10021 MOSAIC WAYTELEPHONE:
(916) 647-4267
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Leilani NittaTIME COMPLETED:
04:45 PM
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On 3/29/24 at 1:35pm Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit. LPA met with the facility administrator, Leilani Nitta, and explained the purpose of today’s visit. The facility is currently licensed to serve 6 developmentally and intellectually disabled adults. Present during this visit, there were four (4) clients in care with three (3) staff on duty. Two clients in care arrived later.

At 9:45am, LPA inspected the facility’s physical plant including but not limited to the kitchen, dining room, client bedrooms, client bathroom, 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. There were no bodies of water on the premises at this time. Outside of the facility was observed to be clean and clear of obstructions. Additionally, LPA observed outdoor furniture for clients’ use and covered area for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed three (3) client bedrooms, and one (1) bathrooms for client use. There are 2 staff rooms in the facility. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. The client rooms were inspected: bedrooms 2, 3, and 4 (from the facility sketch). Bedrooms are shared. Bathrooms were operational and adequately supplied, including with grab bars and non-skid flooring.

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 clients in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 69 degrees F. Water temperature in the bathroom was measured at 107 degrees F. Fire extinguisher was serviced on June 2023. Smoke detectors and carbon monoxide were tested and found to be operable during this visit.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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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: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
VISIT DATE: 03/29/2024
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Medication storage area was observed to be locked and inaccessible to clients in care. LPA observed medication passing during this visit. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. All mandated inspection control posters were posted. LPA observed personal rights poster. Facility has appropriate internet access available for client use. LPA observed sufficient equipment and supplies to meet activity program needs of clients in care.

During this inspection, LPA conducted an audit of facility files, six (6) client files, and four (4) staff files for regulatory compliance. All four staff have criminal background clearances and are associated to this facility. LPA completed 1 staff interview. All client files reviewed contained all required contents including admission agreements, medical assessments, and individual program plan (IPP). All staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts monthly fire drills. LPA requested an updated copy of LIC 308, LIC 500 surety bond and liability insurance.

Due to time constraint, the Department will return to this facility to complete this annual visit. An exit interview was held with Leilani Nitta, Administrator and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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