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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701281
Report Date: 11/19/2024
Date Signed: 11/20/2024 07:21:24 AM

Document Has Been Signed on 11/20/2024 07:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EMPIRE HOME INCFACILITY NUMBER:
392701281
ADMINISTRATOR/
DIRECTOR:		LEGARDA, MARISSAFACILITY TYPE:
735
ADDRESS:290 WEST WILLOW CREEK DRIVETELEPHONE:
(650) 892-9264
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 4CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Marissa Legarda TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct aa Annual visit. LPA was greeted by Licensees, Marissa Legarda and Rudy Golalao explained the purpose of the visit.

This facility will be licensed to hold 4 residents, of which 2 may be non-ambulatory in bedrooms #1 and #2. This facility is also awaiting vendorization from Valley Mountain Regional Center and will accept and hold Level 4I residents.

Current census was 0. A brief interview with Licensees Legarda and Golalao.
A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair.

A tour of the kitchen area was toured. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in the kitchen. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was serviced on 04/29/2024 by the local fire company, Coast Fire Equipment Co.
A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted with no hazards present. Perimeter gate was observed to be in good repair.
A tour of garage was conducted. A washer and dryer was identified. Detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed to meet the residents needs.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EMPIRE HOME INC
FACILITY NUMBER: 392701281
VISIT DATE: 11/19/2024
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A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time.
A tour of two resident restrooms were toured. Hot water temperature was taken to ensure that it was in within 105-120 degrees.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and in compliance at this time.

Based on the observations made during this visit, no deficiencies were observed. An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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