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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:16:51 PM

Document Has Been Signed on 08/04/2023 03:16 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:MONICA FLOR G BUTAYFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Monica ButayTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with Administrator Monica and explained the purpose of the visit.

LPA toured the facility with Administrator Monica. LPA observed 4 resident bedrooms, all of which were fully furnished and free from debris. Resident bathrooms were stocked with soap, paper towels, toilet paper, skid mats, and a trash can. Common areas were observed to be clean and free from debris. No emergency exits were blocked or obstructed. Medications, toxins/cleaning supplies, and sharps were observed to be behind a locked cabinet or closet and inaccessible to residents in care. LPA observed a food supply to meet Title 22 requirements. Hot water was measured at 109.0*F and the temperature inside the home was measured at 74*F. A pull alarm fire system was observed to be in working condition. Fire extinguisher located in the kitchen was fully charged with last check on 10/18/2022.

Staff were observed playing checkers with residents, playing Top 40 music for residents, singing with resident, assisting with ADLs, and completing shift paperwork. PM shift staff were observed reminder staff to drink water, providing snacks, assisting a resident with Zoom Day Program, and finishing cleaning task.

LPA reviewed 4 resident files and 3 staff files. LPA observed staff files to be up to date with required training and documentation. Resident files were completed and current.

LPA requested the following documentation be sent to LPA: LIC 500, LIC 308, Surety Bond, LIC 610D

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 6, no deficiencies were observed. An exit interview was held, a copy of the report was provided.
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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