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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005680
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:41:20 PM


Document Has Been Signed on 03/14/2022 12:41 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:IMMACULATE CARE HOMEFACILITY NUMBER:
347005680
ADMINISTRATOR:MUIRURI, MARYIMMACULATEFACILITY TYPE:
740
ADDRESS:8892 MONTEREY OAKS DRIVETELEPHONE:
(916) 236-7339
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 1DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Balbino Garciagarcia - staffTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 year Annual Inspection. LPA met with staff Balbino Garciagarcia and explained purpose of visit..

LPA and stiff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.
LPA measured the water temperature, temperature measured at 110.2 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers expire February 23, 2023 and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID-19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicate a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left with staff at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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