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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700772
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:06:46 PM

Document Has Been Signed on 04/09/2024 02:06 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CURLY ANNE'S RESIDENCE, INCFACILITY NUMBER:
342700772
ADMINISTRATOR/
DIRECTOR:
DE LOS SANTOS, MARY ANNEFACILITY TYPE:
740
ADDRESS:10435 DANICHRIS WAYTELEPHONE:
(916) 585-9577
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Mary Anne De Los Santos TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA met with facility staff Jennifer L., and explained the purpose of the visit. Facility staff contacted the Administrator of LPAs arrival and arrived to the facility later during the visit.

LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed 5 resident bedrooms, 2 bathrooms, common areas, kitchen/dinning room area, laundry area, and exterior area. Resident bedrooms were clean, organized, free from odors, and fully furnished. Resident bathrooms were clean and equipped with skid matts, hand rails, hand soap, hand sanitizer, paper towels, toilet paper, and a trash can. Common areas were observed to have enough places to sit to conduct activities and/or family visitation. The kitchen was observed to be clean and free from debris. The facility had a food supply that met the minimum requirements of two days of perishable food items and seven days of nonperishable food items. The facility also had an emergency supply of food, water, and supplies. A first aid kit was observed. Chemicals, toxins, medications, cleaning supplies, and sharps were locked away and inaccessible to residents in care. The fire extinguisher was last serviced on 04/01/2024. No emergency exits were obstructed. Residents were observed watching television, being assisted by staff members, doing individual exercises with staff, and being visited by family members.

LPA Valerio reviewed facility files; 3 resident files and 2 staff files. Resident files were up to date with current information, assessments, and care plans. Staff files were up to date and had required annual training.

LPA Valerio requested the following annual documentation be sent to the Regional Office: LIC 500, LIC 308, LIC 610, Liability Insurance, and Administrator Certificate

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being observed today. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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