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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 08/23/2022
Date Signed: 08/23/2022 04:03:04 PM

Document Has Been Signed on 08/23/2022 04:03 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:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR:RAUL CUPINOFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:facility staffTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct the annual inspection. LPA met with facility staff, and explained the purpose of the visit. Staff stated that a staff member tested positive for COVID yesterday on 08/22/22. Staff and residents were tested yesterday and so far everyone was negative. Administrator was not at the facility at the time of arrival.

LPA Valerio inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living room, and outside storage areas of the facility to ensure compliance with Title 22 regulations.

LPA observed the temperature inside the facility was measured at 76 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 106.7*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 10/12/2021.

LPA requested the following documentation be sent by COB 08/29/22: Infection Control Plan, LIC 500, LIC 308, Surety Bond, Administrator Certificate, Emergency Disaster Plan

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with facility staff, and a copy of the report was left for Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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