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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701284
Report Date: 11/07/2023
Date Signed: 11/07/2023 10:51:29 AM

Document Has Been Signed on 11/07/2023 10:51 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:DENALI HOMEFACILITY NUMBER:
052701284
ADMINISTRATOR:SANTOS, ELLERIEFACILITY TYPE:
740
ADDRESS:151 SAGEBRUSH COURTTELEPHONE:
(916) 743-9164
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 0DATE:
11/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ellerie Santos, Elinore Ramas, Dennis Ramas TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Avelina Martinez arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Ellerie Santos, Elinore Ramas, Dennis Ramas, who assisted LPA Martinez in today’s inspection November 17, 2023.

Facility has a fire clearance for two ambulatory clients and two non-ambulatory clients in rooms three and four. Furthermore, the facility has an approved hospice waiver for one. Ellerie Santos will be the Administrator of this facility. The facility administrator has a current certificate.

LPA Avelina Martinez inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The facility was toured both indoors and outdoors with Ellerie Santos, Elinore Ramas, Dennis Ramas.

The facility has a well water system, which was last inspected on October 17, 2023. The facility also has a propane tank, which is serviced every month. The facility has a lock box for P&I funds, and has a current surety bond. The facility has a designated room for medication and facility files. The medication room will be locked. The facility has submitted an infection control plan, natural disaster plan, liability insurance, surety bond, and well water inspection report to the Department. Moreover, the facility has the required postings posted throughout the facility. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The facility has a first aid kit. The facility has a shaded patio area for client use. The facility has no large bodies of water. All resident rooms are furnished, and common areas are furnished. The facility kitchen is sanitary and furnished.

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SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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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: DENALI HOME
FACILITY NUMBER: 052701284
VISIT DATE: 11/07/2023
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All toxins, sharp objects, and other hazards will be stored in a locked cabinet. The facility laundry rooom will be locked, as it will store cleaning supplies and other toxins. The facility will not have cameras in the common areas. The exterior of the facility will have cameras. In addition, the facility has a designated room for staff.

The applicants have passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. The Licensees/Administrator have attended a component three PowerPoint presentation. As a result, LPA Avelina Martinez waived the component three section.

An exit interview was conducted, and a copy of this report was provided to the Applicants.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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