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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 06/21/2021
Date Signed: 06/21/2021 04:12:47 PM

Document Has Been Signed on 06/21/2021 04:12 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:SKYE LUIS CARE HOMEFACILITY NUMBER:
342700589
ADMINISTRATOR:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8705 GREAT CTTELEPHONE:
(916) 914-5119
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Annie RodriguezTIME COMPLETED:
12:30 PM
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On 06/21/21 at 11:35 AM, Licensing Program Analysts (LPA) Christina Valerio and Suong Teh arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio and LPA Teh introduced themselves, met with Administrator Annie Rodriguez, and explained the purpose of the visit. Additionally, LPA Valerio and LPA Teh was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility.

LPA Valerio inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living room, and outside storage areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

The facility has an approved LIC 808 mitigation plan on file. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. COVID-19 informational and hand-washing signage were observed throughout the facility. The facility is able to designated and dedicated a Covid-19 bedroom and bathroom if needed. 

Water temperature reads 110.2° F in the kitchen and 116.5 in the bathroom, within regulatory range of 105 *F and 120 *F. Room temperature reads 75° F. LPA observed the facility to have adequate food supply with emergency food supply kit. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 04/06/21. Medications cabinet was locked.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Administrator Annie Rodriguez. A copy of the report was given to Administrator Annie Lyn Rodriguez.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2021
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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