<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701426
Report Date: 09/09/2024
Date Signed: 09/10/2024 11:19:59 AM

Document Has Been Signed on 09/10/2024 11:19 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:HOUSE OF ELEGANCE RESIDENTIAL HOMEFACILITY NUMBER:
392701426
ADMINISTRATOR/
DIRECTOR:		WARD, BRIAFACILITY TYPE:
735
ADDRESS:2095 BUENA VISTA DRTELEPHONE:
(209) 456-4697
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 4CENSUS: 0DATE:
09/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Monquenette SmithTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Announced Prelicensing visit made out to this facility on 09/09/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility Applicant, Monquenette Smith, who was briefly interviewed at this time.
Current census was 0 residents.
It was learned that this facility will be seeking to accept and retain up to (4) ambulatory only residents through vendorization with Valley Mountain Regional Center at any given time.
It was learned that this facility will have a program to be able to accept and retain Level 4I residents at any given time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located on the second floor of this facility, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located near the garage area, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate for the facility designated Administrator, Brianna Ward, was observed to have been completed with certificate number 7022823735 that was set to expire on 07/16/2026 and in compliance at this time.
Medication cabinet, located in the facility employee office area, was observed to be locked and made
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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: HOUSE OF ELEGANCE RESIDENTIAL HOME
FACILITY NUMBER: 392701426
VISIT DATE: 09/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
inaccessible to the residents at this time.
First aid kit, located in the facility pantry area, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher, located in the facility kitchen area, was observed to have been recently reviewed by the local fire extinguisher company, Butch Young Fire Equipment, on 04/15/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
This facility does have a pool, with spa, in use at this time. This LPA did observe a gate that was locked to make sure that it would be inaccessible at all times. It was learned that this pool area would be off limits and not in use by the facility residents.

Component III was conducted with the facility Applicant, Monquenette Smith, 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: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2