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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701310
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:50:54 PM

Document Has Been Signed on 11/30/2023 02:50 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:ELK VISTA RESIDENTIAL HOME LLCFACILITY NUMBER:
342701310
ADMINISTRATOR:NUNEZ, FABIOLAFACILITY TYPE:
740
ADDRESS:8933 SHADY VISTA CTTELEPHONE:
(916) 582-0296
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Fabiola NunezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/30/23 at 1:00pm and met with Applicant Fabiola Nunez and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection for a change of ownership. LPA was allowed entry into the home that will be licensed for a capacity of 6 non-ambulatory residents of which 1 may be bedridden in bedroom #2 only. Bedroom #7 shall be for staff only. Administrator certificate expires 3/8/2024.

LPA and Fabiola Nunez toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, back yard, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 105.0 *F which is within the required range of 105-120*F. The temperature inside the facility measured at 74*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 area for centrally stored medications to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and exit alarms on every door in the home. The facility has central heating and air. LPA observed the staff and resident files locked and readily available for review. LPA reviewed 2 resident and 2 staff files during this visit.

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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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