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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 04/08/2025
Date Signed: 04/08/2025 11:37:11 AM

Document Has Been Signed on 04/08/2025 11:37 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
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: 6DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Annie Lyn RodriguezTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 4/8/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their annual inspection visit. LPA met with the administrator, Annie Lyn Rodriguez, and stated the purpose of this visit. Present today visit were 6 residents in care with 2 staff on duty.
It was learned that there were (3) residents under the care of hospice at this time. This facility has an approved hospice waiver for (3) residents at any given time.
This facility also has, on file, a program to accept and retain residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. During the inspection of the kitchen, LPA observed a small fridge that is locked; per discussion with the administrator, it contains resident's medication that require refrigeration.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the office area, was reviewed. The medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of 3 of 4 resident bedrooms and 1 of 2 restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperature was taken in 1 of 2 bathroom and measured at 109 degrees Fahrenheit. Room temperature during this visit was measured at 71 degrees Fahrenheit.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 342700507
VISIT DATE: 04/08/2025
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Linen closet, located in the resident hallway cabinet, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 3/5/25. Facility conducts quarterly emergency drills.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted and found to be in good repair at this time.

A review of (3) facility resident files was conducted and noted on the following LIC 858. 1 of 3 resident did not have PRN authorization on file. Per discussion with the administrator, she will obtain one from hospice doctor.
A review of (2) facility personnel files was conducted and noted on the following LIC 859. Both staff reviewed are associated to this facility and have current 1st aid/CPR certificate.

During this visit, 2 residents were watching TV at the living room, 2 residents were in their bedroom and one resident had a visitor from an outside agency.

The following forms and documents were obtained during this visit:
  • LIC 308 - Designation of administrative responsibility
  • LIC 409 - Administration organization
  • LIC 500 - Personnel report
  • LIC 610E - Emergency Disaster Plan
  • Lease Agreement

No deficiencies were observed from today's visit.
Exit interview was conducted and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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