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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004571
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:26:04 PM

Document Has Been Signed on 07/21/2022 01:26 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:LADIORAY HOME INC.FACILITY NUMBER:
347004571
ADMINISTRATOR:MINA, LUZ M.FACILITY TYPE:
735
ADDRESS:4510 CAREYBACK AVENUETELEPHONE:
(916) 428-0392
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Vanjasper Mina - StaffTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required Annual 1 Year Inspection Visit. LPA met with staff and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 4 clients. Administrator Certificate Expires 10/05/2022.

LPA and staff toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the facility conducts fire drills monthly. LPA observed medication stored and locked away inaccessible to persons in care. LPA observed medication logged into Medication Administration record (MARS).

The hot water was measured at 109.3 *F which meets the requirement of 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.
The first aid kit was found in compliance. LPA observed a pull alarm system, fire extinguisher(s) are current,, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable food stored for emergency. There were perishable foods for a minimum of two days that shall be maintained on the premises at all times. The sharp objects that are : Knives, forks, and spoons locked away.

LPA reviewed (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid/CPR certifications on file. LPA reviewed (2) client files and all required documents were present in file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed. Exit interview held, copy of report given to staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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