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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701284
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:37:45 AM

Document Has Been Signed on 08/08/2024 10:37 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/
DIRECTOR:
SANTOS, ELLERIEFACILITY TYPE:
740
ADDRESS:151 SAGEBRUSH COURTTELEPHONE:
(916) 743-9164
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 2DATE:
08/08/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ellerie SantosTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 08/08/2024 at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an post required inspection. LPA Martinez met with Ellerie Santos and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

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.

The LPA Martinez toured the facility with Ellerie Santos on 08/08/2024 at 10:30 AM.

LPA Martinez reviewed two client files and one staff files, which the files were complete and maintained. The facility has an infection control plan and a natural disaster plan. The last fire drill was conducted on July 02, 2024. The facility has a first aid kit, and a locked office for medication storage. LPA Martinez reviewed one medication administration record (MAR), which was complete and maintained. The facility has an adequate food supply. All common areas, bedrooms, bathrooms, laundry room, and kitchen were sanitary and clean. The exterior of the facility is clear of debris, and the facility has a furnished patio for client use. The facility water temperature measured at 105 degrees, and the facility temperature measured at 73 degrees.

Based on this post pre-licensing visit, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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