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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700447
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:55:47 AM

Document Has Been Signed on 11/19/2021 11:55 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:ENSLEN HOUSEFACILITY NUMBER:
502700447
ADMINISTRATOR:RODRIGUEZ YIEN, ELIZABETHFACILITY TYPE:
735
ADDRESS:1113 ENSLEN AVETELEPHONE:
(925) 594-0124
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 6CENSUS: 0DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Staff Clara RodriguezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 11/19/2021. LPA met with staff Clara Rodriguez and explained the purpose of the visit. Elizabeth Rodriguez is the Administrator and holds certificate #6001227735 that expires on 06/28/2023. LPA was informed that the facility does not have any clients at this time due to (VMRC) Valley Mountain Regional Center delays with COVID for vendorization.

This facility is a single story building licensed to serve six (6) ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (109) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 10/29/21. Thermostat observed at (70) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms need updating and submitted to CCLD by 11/22/2021:
LIC 308 copy of administrator certificate
LIC 500
LIC 610
No Deficiencies were found during todays visit. Exit interview held with Clara Rodriguez and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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