<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 02/21/2023
Date Signed: 02/21/2023 11:51:31 AM

Document Has Been Signed on 02/21/2023 11:51 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
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: 5DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual inspection. LPA met with Administrator Annie Rodriguez, and explained the purpose of the visit.

LPA and Administrator toured the facility to ensure compliance of Title 22 regulations. LPA also completed the infection control tool. LPA observed the residents bedrooms, resident bathrooms, kitchen, garage, living room area, common area, and dinning room. LPA observed 2 staff on shift along side 2 hospice care staff. The facility common areas were observed to be clean and free from debris. Staff were observed to be cooking lunch, assisting residents, and doing paperwork. Residents were observed to be having a family visit, watching television, and reading the newspaper. The bathrooms were observed to have necessary items. Hot water was measured at 111.9*F. Temperature inside the home was observed to be 74*F. The facility was observed to have a supply of perishable foods for seven days and a supply of non-perishable food for a minimum of two days. An emergency supply of food and water was observed. An emergency supply of lights, blankets, and first aid kit was observed. The fire extinguisher was observed to be up to date with last check on 03/31/2022.

LPA obtained copies of annual documentation for facility file.

No deficiencies were observed during today's visit. An exit interview was held, and a report was provided to Administrator Annie Rodriguez.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1