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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701052
Report Date: 01/05/2022
Date Signed: 01/11/2022 09:18:20 AM

Document Has Been Signed on 01/11/2022 09:18 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ELIZABETH CARE HOMEFACILITY NUMBER:
392701052
ADMINISTRATOR:FAJARDO, GERALDINEFACILITY TYPE:
735
ADDRESS:3674 POPOLOTELEPHONE:
(510) 289-3848
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 0DATE:
01/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Geraldine Fajardo, AdministratorTIME COMPLETED:
03:15 PM
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On 01/05/2022, Licensing Program Analyst (LPA) T.White arrived announced to conduct a pre-licensing inspection. LPA met with Administrator, Geraldine Fajardo and Larry Angel. LPA explained the purpose of the pre-licensing inspection. Fire clearance is licensed for 6 clients, which 2 may be non-ambulatory and 1 may be bedridden.

LPA toured the facility including but not limited to: physical plant, food service, common area, bedrooms, bathrooms, kitchen and medication storage.

LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed kitchen was clean and in good repair. Facility has (7) seven day supply of non-perishable and (2) two day of perishable food supply. Client bedrooms were checked and were observed to be adequately furnished. LPA observed adequate supply of linens. Activity supplies available. LPA tested water temperature in client's shared bathroom measured at 106.3 degrees F. LPA observed locked areas where items such as but not limited to, knives, medication, and toxins will be stored inaccessible to clients. LPA toured the back yard to ensure safety and side of the house to ensure safety.

Smoke detector and carbon monoxide in operating condition during inspection. Fire extinguisher last serviced on 05/21/2021. First aid kit observed to be complete. LPA observed mitigation plan completed. Emergency Disaster Plan last posted on 04/01/2021. Facility staff has required background checks and fingerprint clearances.

LPA White discussed the Component III with Administrator. Based on observation and interview it appears the facility is ready to be licensed. The report will be forwarded to the centralized application unit for continued processing. No deficiencies cited during inspection.
Exit interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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