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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700090
Report Date: 09/07/2021
Date Signed: 09/07/2021 12:18:11 PM

Document Has Been Signed on 09/07/2021 12:18 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ELK RIDGE OAKSFACILITY NUMBER:
342700090
ADMINISTRATOR:LABIOS, JENNIFERFACILITY TYPE:
740
ADDRESS:8724 ELK RIDGE WAYTELEPHONE:
(916) 685-2392
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mona LisaTIME COMPLETED:
12:30 PM
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On 09/07/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 11:20 AM, LPA met with a staff member at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

At approximately 11:40 AM, LPA met with Administrator Mona Lisa and explained the purpose of the visit. LPA toured the physical plant with the Administrator. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. At 11:45 AM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris.

The clients' bedrooms were inspected and all had required lighting and furniture.
Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked.

At approximately 11:50 AM, LPA completed the facility tour for Infection Control with the Administrator. This report was reviewed with the Administrator. No deficiencies were cited today.

Exit interview conducted with the Administrator. A copy of this report will be emailed to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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