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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005521
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:14:18 PM


Document Has Been Signed on 10/10/2023 12:14 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: 5DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Monalisa SilapanTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/10/23 at 9:30AM. Administrator Certificate expires for Lovelie Arcega 6/15/2024.

LPA met with Ninalyn Menez, Caregiver and Monalisa Silapan and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in room 2. The facility has an approved hospice waiver for 2 residents to receive hospice care services. There is 1 resident utilizing hospice services at this time. The most current emergency drill was conducted on 10/1/23.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and conversed with residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. 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 111.1*F 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. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Administrator Certificate-Updated, Designation of Facility Responsibility (LIC308), Liability Insurance, Personnel Report (LIC500), and Emergency Disaster Plan (610E)

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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