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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700772
Report Date: 05/28/2021
Date Signed: 05/28/2021 11:24:58 AM

Document Has Been Signed on 05/28/2021 11:24 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:CURLY ANNE'S RESIDENCE, INCFACILITY NUMBER:
342700772
ADMINISTRATOR:DE LOS SANTOS, MARY ANNEFACILITY TYPE:
740
ADDRESS:10435 DANICHRIS WAYTELEPHONE:
(916) 585-9577
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 2DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mary Anne De Los SantosTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 05/28/2020. LPA met with Mary Anne De Los Santos and explained the purpose of the visit. Mary Anne De Los Santos is the Administrator and holds certificate #6039600740 that expires on 05/13/2022.

This facility is a single story building licensed to serve six (6) non-ambulatory residents, and licensed to serve up to 3 residents with a hospice waiver. facility has 1 shared room and 4 private rooms. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (105.2) degrees Fahrenheit in the kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke detectors are in compliance with fire safety. Fire extinguisher last serviced February 22 of 2021. Thermostat temperature was observed at 74 degrees Fahrenheit.

LPA observed linen closets to be stocked. LPA observed centrally stored medications and toxins was kept locked and inaccessible to clients. LPA staff associations to the facility. First aid kit was checked and is complete.
The following forms were collected during today's visit on 05/28/2021
LIC 308
LIC 500
LIC 610E
No deficiencies were observed during today's inspection visit.
Exit interview held with Mary Anne De Los Santos and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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