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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701052
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:00:04 PM

Document Has Been Signed on 11/04/2022 04:00 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:ELIZABETH CARE HOMEFACILITY NUMBER:
392701052
ADMINISTRATOR:FAJARDO, GERALDINEFACILITY TYPE:
735
ADDRESS:3674 POPOLO CIRCLETELEPHONE:
(510) 289-3848
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 2DATE:
11/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Geraldine Fajardo, AdministratorTIME COMPLETED:
04:15 PM
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On 11/4/22 at 1:45 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a health and safety check. Upon LPAs arrival, Caregiver Chita Fortes was present at facility and contacted Administrator Geraldine Fajardo who arrived a bit later. LPA met with Administrator Geraldine Fajardo and explained the purpose of the visit.

LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. There are 2 clients and 2 caregivers present during this visit.

LPA observed the facility is clean and in sanitary condition. LPA observed 2 day perishables and 7 day non-perishables food items. The hot water measured at 118.2 degrees Fahrenheit which is within the required range of 105-120*F. The temperature inside was observed at 71 degrees Fahrenheit which is within the required range of 68-85*F. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed knives and toxins to be locked away and inaccessible to clients.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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