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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005352
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:42:18 PM

Document Has Been Signed on 06/07/2021 03:42 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:ELLIE'S SENIOR CARE HOME, INC.FACILITY NUMBER:
347005352
ADMINISTRATOR:TRAVIS STEVENSONFACILITY TYPE:
740
ADDRESS:3708 N EDGE DRIVETELEPHONE:
(916) 977-3679
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Joanne Lozano and Travis StevensonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA met with Travis Stevenson and explained the purpose of the visit on 06/7/2021.

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

The LPA toured the facility with Joanne Lozano on 06/07/2021 at 2:31 PM. Administrator holds current certificate # 602793740 and expires on 11/28/2021. The facility is licensed for 6 non-ambulatory residents. This facility has a hospice waiver for 3 and a dementia program. The facility currently has 5 residents.

The facility has submitted a mitigation plan to CCLD. The mitigation plan has been approved by CCLD. One central entry point has been designated for universal entry screening. All visitors, staff, and essential workers are screened for Covid-19 symptoms. Additionally, the facility conducts 25% surveillance Covid-19 testing. Moreover, hand hygiene postings are posted in bathrooms. The facility also has covid-19 cleaning, cough etiquette, and covid-19 screening postings throughout the facility. The facility provides hand sanitizer to residents.

The facility conducts hourly disinfection cleaning. The facility dining area is sanitary, and dining table chairs are spaced six feet apart. Facility common areas are sanitary, and the furniture is spaced 6 feet apart. Fire extinguishers are in good repair, and the facility temperature is 77 degrees. Facility smoke/carbon detectors are in good repair . The facility exterior patio is fully furnished and sanitary.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. Exit interview held and a report given at the end of the visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2021
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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