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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701298
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:40:32 PM

Document Has Been Signed on 07/24/2023 01:40 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:ASHFORD CARE HOMEFACILITY NUMBER:
342701298
ADMINISTRATOR:TOLENTINO, ELAINEFACILITY TYPE:
740
ADDRESS:1205 GRAND RIVER DRTELEPHONE:
(916) 228-4601
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
07/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elaine TolentinoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/24/23 at 9:45am and met with Applicant(s) Elaine Tolentino and Marivic Daduya and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the home that will be licensed and fire cleared for a capacity of 6 Non-ambulatory residents. Administrator certificate expires for Elaine Tolentino on 8/14/24. LPA observed that the facility has submitted a Infection Control Plan.

LPA and Elaine Tolentino and Marivic Daduya toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed residents participating in individual activities during this visit. LPA observed the kitchen area, dining area, bedrooms, bathroom, and storage areas. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility, as well as a gated pool. The hot water temperature measured at 120*F which is within the required range of 105-120*F. The temperature inside the facility measured at 75 *F which is within the required range of 68-85*F.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s). Facility has central heating and air.

LPA observed the area where the staff and resident files are locked and readily available for review.

Component III conducted - There are no objections to licensure at this time. -Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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