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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:53:16 PM

Document Has Been Signed on 10/15/2024 02:53 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEXIE RAE'S CARE HOMEFACILITY NUMBER:
342700507
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
10/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:43 PM
MET WITH:Annie Lyn RodriguezTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/15/24, at 1:43pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.. LPA met with the Administrator, Annie Lyn Rodriguez (AD) and stated the purpose of the visit. Present in today's visit were 3 residents in care with 1 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident.

LPA conducted a physical inspection of the facility. LPA observed residents were in their bedroom watching TV. Room temperature was measured at 74*F and hot water temperature was measured at 118*F in one of the bathrooms. 3 of 4 bedrooms were inspected and were observed to be clean and good repair. 1 of 2 bathrooms was inspected and was observed to be maintained and in good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Kitchen was observed to be clean at this time. The garage was inspected and was observed to be used as storage only. NO evidence of staff living in the garage. Stipulation was observed in a conspicuous place at the office desk area.
During this visit, LPA conducted review of 3 of 3 resident records and 4 staff records. Resident records reviewed have updated Physican's Report and Needs and Services Plan. 4 of 4 staff record reviewed have current 1st Aid/CPR Certificates and ongoing training. Per stipulation, facility conducts monthly staff training. Last training was conducted on 9/27/24. No new admissions since last visit. A reminder was provided to AD that under the stipulation, she cannot accept anyone with prohibited health condition.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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