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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005521
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:47:25 PM


Document Has Been Signed on 10/12/2022 03:47 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:CARE GROUP AT HEATHMAN WAY, THEFACILITY NUMBER:
347005521
ADMINISTRATOR:JENNIFER LABIOSFACILITY TYPE:
740
ADDRESS:9473 HEATHMAN WAYTELEPHONE:
(916) 667-9414
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Monalisa SilapanTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct the annual inspection. LPA was met by facility staff, and explained the purpose of the visit. Facility staff confirmed zero residents or staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

Administrator Monalisa Silapan arrived to the facility. Administrator Monalisa stated Jennifer is no longer the administrator and will send supportive documents to LPA.

Licensee and LPA toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 5 bedrooms and 2 bathrooms, all of which were in clean condition with required furniture and furnishings. The common areas, kitchen area, garage, and living space were observed to be organized, free from debris/dust, and clean. Facility staff were observed cleaning, assisting residence with ADLs, and engaging with residents. The facility had maintenance staff cleaning the backyard. No obstructions to emergency exits were observed. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 106.3F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility to be in working condition.

LPA requested the following documentation: LIC 500, LIC 308, Administrator Certificate, LIC 610, Infection Control Plan, and Liability Insurance

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held with Administrator Monalisa , copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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