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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701369
Report Date: 05/29/2024
Date Signed: 05/30/2024 02:26:50 PM

Document Has Been Signed on 05/30/2024 02:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CONNECT CARE HOME LLCFACILITY NUMBER:
392701369
ADMINISTRATOR/
DIRECTOR:		LUGTU, LIESCLE DOLORFINOFACILITY TYPE:
735
ADDRESS:1465 CRANE STREETTELEPHONE:
(209) 328-1834
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 4CENSUS: 0DATE:
05/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Benigno and Liescle LugtuTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 05/29/2024 by Licensing Program Analyst (LPA) Charlie Yang and Licensing Program Manager (LPM) Liza King who was met by the facility designated Administrator, Liescle Lugtu, and her husband, Benigno Lugtu, at this time. A brief interview was conducted with the facility designated Administrator and her husband at this time.
It was learned that this facility was seeking licensure to accept and retain up to 4 non ambulatory residents at any given time. This facility was also seeking vendorization through Valley Mountain Regional Center (VMRC) to be able to retain and accept (4) Level 4I residents at any given time.
Current census was 0 residents.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication closet, located in the living room hallway, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CONNECT CARE HOME LLC
FACILITY NUMBER: 392701369
VISIT DATE: 05/29/2024
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A tour of the resident restrooms (2) was conducted.
Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cleaning supplies, detergents, and bleach were observed to be stored in the garage cabinets and were inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits, located in the medication closet, were observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area and was just recently purchased on 10/26/2023 and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

Component III was conducted by this LPA along with the facility designated Administrator and her husband at this time.

This facility was found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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