<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700772
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:25:31 PM

Document Has Been Signed on 04/12/2022 12:25 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: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: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Richard Bacud - Assistant AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Visit. LPA met with Assistant Administrator and explained the purpose of the visit. Administrator Certificate #6039600740 for Mary Anne De Los Santos 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 with Assistant Administrator 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 112.3 degrees Fahrenheit in the kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers expire 4/13/22 and smoke detectors are in compliance with fire safety. Thermostat temperature was observed at 75 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.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

Exit interview held with Assistant Administrator and a copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1