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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 575001806
Report Date: 11/03/2023
Date Signed: 11/03/2023 05:12:44 PM


Document Has Been Signed on 11/03/2023 05:12 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ST. CLAIRE'S HOME FOR THE ELDERLYFACILITY NUMBER:
575001806
ADMINISTRATOR:DUGYON, JOSHUAFACILITY TYPE:
740
ADDRESS:2551 MEADOWLARK CIRCLETELEPHONE:
(916) 307-8068
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:6CENSUS: 4DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Juliet Dugyon, LicenseeTIME COMPLETED:
05:08 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection. There are 4 residents, all were at Day Program at the beginning of the inspection. There were two caregivers at the facility at the time of inspection.

LPA toured the facility with carestaff and residents on 11/03/2023 at approximately 3:15 PM. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins and sharps for the kitchen are stored and locked in laundry room. There was adequate dry food for at least a week and fresh foods for at least 2 days. All food was stored appropriately and dated. Medications were stored in locked medication closet making them inaccessible to residents and staff that do not handle medications. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Each bathroom had soap and paper towels. All postings were up and visible as required. Facility has a sufficient supply of personal protective equipment (PPE). Facility has an Infection Control Plan. The fire extinguisher was serviced on October 16, 2023. The carbon monoxide detector was tested and operational. The facility has a central fire alarm system.
The last Fire Drill was on 10/02/2023. The water temperature was 115.3 F.
Residents were clean and appropriately dressed.

No deficiencies during today's inspection.
No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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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