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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 04/27/2022
Date Signed: 04/27/2022 10:11:50 AM

Document Has Been Signed on 04/27/2022 10:11 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
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) 685-6910
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a required 1-year annual. LPA Valerio confirmed there are 0 residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio met with Administrator/Licensee Annie Lyn Rodriguez and explained the purpose of the visit.

LPA Valerio completed the infection domain tool. Facility staff are said to clean multiple times per shift. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed at the front area of the home.

LPA Valerio toured the physical plant interior and exterior to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. A two-day supply of perishable foods and a seven-day supply of non-perishable foods were observes. An emergency supply of food and water was observed. Medication cabinet, cleaning supplies, and sharps were locked away and inaccessible to residents in care. A first aid kit was observed to be fully stocked with necessary items in the medication cabinet. Hot water was measured at 106.1*F. Room temperature was set to 74*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Fire extinguishers were observed to be charged and within compliance with last check on 03/31/2022. The backyard had a large sitting area for residents and/or visitors.

During the visit, staff was observed to care for residents needs and assisting with ADLs.

LPA requested facility documentation: LIC 610D, LIC 308, LIC 500, Liability Insurance

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: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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