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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005514
Report Date: 10/06/2022
Date Signed: 10/06/2022 06:48:37 PM

Document Has Been Signed on 10/06/2022 06:48 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:WESTHAM FACILITYFACILITY NUMBER:
347005514
ADMINISTRATOR:MARCUS HUFFFACILITY TYPE:
735
ADDRESS:4900 WESTHAM WAYTELEPHONE:
(714) 234-4776
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:41 PM
MET WITH:Michael OlivaTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA met with facility staff, and explained the purpose of the visit. Facility staff/designated administrator Michael Oliva arrived to the facility shortly after arrival.

LPA Valerio and facility staff 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 also conducted the infection control domain tool. LPA requested a copy of their Infection control plan be sent for review. LPA observed the facility to have hand washing signs posted at the front door and throughout the facility. The facility has a designated infection control lead.

Water temperature reads 120F, within regulatory range of 105 *F and 120 *F. Room temperature reads 72° F. LPA observed the facility to have adequate food supply with emergency food supply kit. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke detectors, carbon detectors, and fire extinguishers were observed to be in good repair. Staff stated no medications are being taken at this home.

LPA requested the following documentation be sent to LPA for facility file: LIC 500, LIC 308, Updated Administrator Certificate, Surety Bond, Emergency Disaster Plan, Infection Control Plan, Infection Control Plan for Monkey Pox, and updated Resident Roster

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Michael, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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