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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 11/09/2021
Date Signed: 11/09/2021 01:05:40 PM

Document Has Been Signed on 11/09/2021 01:05 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:LEXIE RAE'S CARE HOMEFACILITY NUMBER:
342700507
ADMINISTRATOR:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 914-5119
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA Valerio met with Administrator Annie Lyn Rodriguez, introduced herself, and stated the purpose of today’s visit. LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility that is licensed to serve a total capacity of 6 clients. Administrator confirmed residents and staff have not displayed signs or symptoms of COVID-19 in the last 10 days.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has an approved LIC 808 mitigation plan on file. LPA observed the facility to have a first aid kit, hand washing signage, and COVID-19 informational signage posted at the front door and throughout the facility. The facility is able to dedicate a COVID-19 bathroom and bedroom if needed. Facility has a minimum 30 day supply of PPE and a PPE cart readily available for use.
 
LPA observed the temperature inside the facility was measured at 76 *F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 111.1 *F and 117.0 *F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of food and water was observed. LPA observed the centrally stored medications area and chemicals to be locked and inaccessible to clients. LPA Valerio observed a fire alarm system, fire extinguisher(s) with last check on 04/06/21, smoke and carbon monoxide detectors, central heating, and air in the facility. LPA requested facility documentation: LIC 610E, Liability Insurance, LIC 500, LIC 308
 
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited.  Exit interview held with Administrator Annie Lyn Rodriguez and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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