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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700585
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:30:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/02/2022 03:30 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:INDOCARE HOUSE 2FACILITY NUMBER:
342700585
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8604 BANFF VISTA DRTELEPHONE:
(916) 686-1253
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresita Lomendehe, LicenseeTIME COMPLETED:
11:00 PM
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Licensing Program Analysts (LPA) Renee Campbell arrived unannounced to conduct an Annual Required inspection on this date.

LPAs inspected the facility, which included but not limited to the bathrooms, kitchen, living room and the outside area of the facility. LPAs observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Grab bars and non-skid mats were observed in bathrooms and throughout the facility. Food supply was stored and prepared in a healthful manner. Clients received Breakfast, snacks and a hot lunch. The hot water temperature in the client's bathroom measured 110 degrees Fahrenheit. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Staff members have a current first aid kit and CPR. First aid kit was checked and is complete and disaster drill is current.

No deficiencies were cited during this annual inspection.

Exit interview conducted. Report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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