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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701052
Report Date: 01/04/2023
Date Signed: 01/04/2023 10:15:56 AM

Document Has Been Signed on 01/04/2023 10:15 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 POPOLO CIRCLETELEPHONE:
(510) 289-3848
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 2DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Geraldine Fajardo - AdministratorTIME COMPLETED:
10:30 AM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. There are two (2) clients in the facility.

LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. Client bedrooms, bathrooms, hallway, kitchen, family room and dining area was observed. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature was observed to be 114.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 68 degrees Fahrenheit. Food supply is adequate for 2 day perishable and 7 day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher was inspected on 9/27/2022 and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients.

LPA reviewed two (2) staff records and two (2) client records. All files were complete. Staff are fingerprint cleared and first aid certified.

LPA observed the medication and the MARS sheets. Medications appear to be documented appropriately.

LPA requested the following documents to be submitted via email by January 11, 2023: Administrator Certificate, Lease Agreement, LIC 308 - Designation of Administrator Responsibility, and LIC 500 Personnel Summary

No deficiencies observed or cited on today's date.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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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