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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005517
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:27:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ELIM RANCHFACILITY NUMBER:
347005517
ADMINISTRATOR:EDWARD LEEFACILITY TYPE:
740
ADDRESS:8149 SANTA JUANITATELEPHONE:
(916) 759-9019
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Farah Razo, administratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 05/28/2021 to conduct a Case Management Visit regarding staff being fingerprint cleared at facility. Community Care Licensing (CCL) was informed that some staff are possibly not fingerprint cleared, which resulted in today’s visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted administrator to complete a facility risk assessment screening. LPA was greeted by Farah Razo (Designated Administrator) upon arriving at facility and was screened.

During visit, LPA reviewed six (6) staff records and conducted an interview with Farah Razo. LPA asked Farah if any new staff have been hired that have not been able to get cleared, and was informed no new hires at this home at this time. LPA and Farah reviewed facility roster pulled from Guardian together and confirmed employment status of those listed. The six (6) records reviewed were up to date, with current Background Clearance Transfer Request forms (LIC 9182) and Criminal Record Statement (LIC 508). Through records reviewed and interviews conducted, LPA did not suspect non-fingerprinted staff to be working at the facility at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report emailed to administrator..
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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