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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701310
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:06:29 PM

Document Has Been Signed on 01/24/2024 12:06 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: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:
01/24/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Fabiola NunezTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 1/24/24 at 8:30AM to conduct a Post Licensing visit. LPA met with Fabiola Nunez and explained the purpose of the visit. Licensing Fees are current. Administrator Certificate expires on 3/8/24.

LPA observed a LIC308 Designation of Facility Responsibility on file. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 1 may be bedridden in room #2. Facility has approval for 2 residents to receive hospice care services. There is 0 residents receiving hospice care services and 0 bedridden at this time. LPA observed residents eating breakfast during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility.

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 temperature inside the facility was observed to be at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.5*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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