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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700585
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:14:10 AM

Document Has Been Signed on 12/07/2023 11:14 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: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:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Orpha ManalansanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/7/23 at 9:00AM to conduct a Required - 1 year inspection visit. LPA met with Caregivers Orpha Manalansan and Luisita Manalansan and explained the purpose of the visit. Caregiver Orpha Manalansan contacted the Administrator regarding todays visit. Caregiver(s) are finger print cleared and associated to the facility. Licensing fees are current. Administrator certificate expires 7/1/2024. Licensing Information System (LIS) Facility Personnel Report Summary (roster) provided during this visit. LPA observed the facility has an Infection Control Plan on file. The facility is licensed for a capacity of 6 non- ambulatory residents of which 6 may receive hospice care services. LPA observed residents participating in individual activities during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The last documented quarterly emergency drill was conducted on 9/1/23. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.9*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 2 staff and 1 resident file during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate-Updated, Liability Insurance-updated, Any updates/Addendum to Infection Control Plan

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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