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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700767
Report Date: 07/21/2021
Date Signed: 07/21/2021 04:40:58 PM

Document Has Been Signed on 07/21/2021 04:40 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:ALLTRUE CARE LLCFACILITY NUMBER:
342700767
ADMINISTRATOR:KACHAN, VICTORIAFACILITY TYPE:
740
ADDRESS:9977 WYLAND DRIVETELEPHONE:
(530) 215-8388
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
07/21/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Victoria KachanTIME COMPLETED:
04:39 PM
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On 7/21/21 at 2:57pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a post licensing inspection visit. LPA was greeted by caregiver and LPA explained the purposes of the visit. Administrator Victoria Kachan arrived at 4:17PM and LPA explained the purpose of the visit.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations.

Facility is a 6-bed facility with a current census of 3. LPA was screened upon entry for temperature and asked to sign in. Facility has 6 bedrooms and 3 bathrooms. One bedroom is for staff use. There is a dining room off the kitchen area. Backyard has no obstructions to exit areas. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. Administrator certificate posted and expires 08/05/2022. COVID mitigation tool was used for this visit. Facility had appropriate lighting throughout.

The facility has submitted a COVID mitigation plan which was approved on 5/4/21. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Refrigerator temperature measured at 37*F. Freezer temperature measured at 0*F. Linen closet was well stocked with appropriate amounts. Water temperature reads 105.6*F in the bathroom and room temperature reads 78*F. (Cont. on 9099C)
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALLTRUE CARE LLC
FACILITY NUMBER: 342700767
VISIT DATE: 07/21/2021
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 LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. First extinguisher was checked 4/12/21.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Victoria Kachan and a report was given to Victoria

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC809 (FAS) - (06/04)
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