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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004525
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:40:24 AM

Document Has Been Signed on 03/22/2023 11:40 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: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:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Leilani NittaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit on 3/22/23. LPA met with Administrator Leilani Nitta and Co-Administrator Justin Nitta and explained the purpose of the visit. Administrator Leilani holds current certificate # 6008957735 and expires on 11/28/23. The facility is licensed to serve 6 ambulatory developmentally disabled adults. There are currently 6 clients who reside at this facility. During today's visit, clients were at day program. LPA toured the facility with Justin Nitta on 3/22/23 at 9:20 AM

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one main Covid-19 screening point and has Covid-19 posting throughout the facility. The facility has 30 days supplies of PPE. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The hot water temperature was observed to be 117.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 68 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
VISIT DATE: 03/22/2023
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LPA requested client and staff files for review. LPA reviewed (4) client files and (4) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this visit, there were no deficiencies cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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