<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005517
Report Date: 08/30/2023
Date Signed: 08/30/2023 11:45:29 AM


Document Has Been Signed on 08/30/2023 11:45 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ELIM RANCHFACILITY NUMBER:
347005517
ADMINISTRATOR:EDWARD LEEFACILITY TYPE:
740
ADDRESS:8149 SANTA JUANITA AVENUETELEPHONE:
(916) 759-9019
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator, Farah CucciaTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/30/23, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a required annual inspection. LPA met with administrator, Farah Cuccia and explained purpose of inspection.

LPA and Administrator toured the interior and exterior of the facility including the common areas, residents bedrooms and bathrooms, kitchen, laundry area, medication room, staff room and outside area. LPA observed the home to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed various infection control posters throughout as well as other required postings, including House Rules and personal rights. Inside temperature was observed to be 74* F. Fire extinguisher is ready for emergency use. Facility conducts quarterly fire and disaster drills. The facility has a large back yard area with seating. Facility has a pool which was locked and properly secured during inspection. LPA observed locked toxins in the laundry area and locked medications in a separate room. LPA observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPA observed paper towels, soap, sanitizer, trash cans and hand-washing posters in the bathroom. Smoke/monoxide alarms were in working order.

LPA reviewed 2 residents and 2 staff files. LPA reviewed medications of 2 residents comparing with physician orders and find no errors. All residents files have required paperwork. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed.

No deficiencies were observed or cited today. Exit interview conducted.
A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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