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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:16:02 PM

Document Has Been Signed on 08/12/2024 04:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR/
DIRECTOR:		RAUL CUPINOFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Monica ButayTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with administrator Monica Butay and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). This facility's fire clearance allows one non-ambulatory client only. LPA Moleski observed that in their most recent LIC 602s, both R2 and R4 were determined to be non-ambulatory by their physicians.

LPA Moleski toured the facility with Butay and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed two staff members (S4-S5) and one resident (R3).

This facility is being cited per 22 CCR Section 80020(a). An exit interview was held with Butay. Appeal rights and a copy of this report was left with Butay.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/12/2024 04:16 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/12/2024 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEER HOME 2
FACILITY NUMBER: 347005345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee retained two residents who were considered non-ambulatory per their physicians while being cleared for only one, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee agrees to re-assess one or both of these residents. Licensee will provide a written plan of correction to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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