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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:40:20 PM

Document Has Been Signed on 03/08/2022 03:40 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) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA Valerio confirmed with staff that there are 0 staff or residents that have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA temperature was taken prior to being allowed in the facility/

LPA Valerio met with Licensee Annie Lyn Rodriguez and facility staff. The infection control domain tool was completed during the visit. PIN 22-07 was review with Administrator. The Emergency Disaster Plan, Mitigation Plan, LIC 500 Personnel Report, Liability Insurance, and Co-Licensee Administrator Certificate Monalisa Silapan (Certificate Number 6025978740 Expiration Date: 03/23/2023) was observed to be on file and up to date. LPA obtained copies for regional office facility file.

Facility Staff and LPA Valerio toured the physical plant to ensure compliance of Title 22 regulations. LPA observed the kitchen to have an emergency supply of food, a locked cabinet for sharps and cleaning supplies, a supply of perishable foods for seven days, and a supply of non-perishable food for a minimum of two days. Resident rooms were furnished with required furniture and were clean and free from debris. Common areas are said to clean every shift and observed by LPA to be clean. Resident bathrooms were fully stocked with necessary items, including soap, hand sanitizer, paper towels, and a trash can with a lid. A pull alarm system was observed to be at the facility and in working condition. The fire extinguisher was fully charged with last check on 04/06/2021. The hot water was measured at 113.7*F, which is within the required range of 105*F - 120*F.

Residents were observed to have family visits, watching TV, and taking naps. Staff were observed engaging in conversations with the residents.

Per the California Code of Regulations, Title 22, Division 6,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: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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