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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701336
Report Date: 03/20/2026
Date Signed: 03/20/2026 11:34:26 AM

Document Has Been Signed on 03/20/2026 11:34 AM - 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:ELIXIR CARE HOMEFACILITY NUMBER:
342701336
ADMINISTRATOR/
DIRECTOR:		DULAY, MARIA GFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 565-1468
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 6CENSUS: 4DATE:
03/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maria Gloria DulayTIME VISIT/
INSPECTION COMPLETED:
11:52 AM
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On 3/20/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at this facility unannounced to conduct a required annual visit. Upon arrival, LPA met with Care staff Rasela Changkwan (S2) and explained the purpose of today’s visit. S2 called the Administrator, Maria Gloria Dulay (S1), and informed them of LPA’s presence. S1 arrived around 11:00AM.

This Residential Care Facility for the Elderly facility is a single story building licensed to serve 6 non-ambulatory adults within age range of 60 and over, with a hospice waiver for six. The census is 4 residents and two staff, S2 and Roman Murallo (S3).

LPA Tamayo inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Tamayo observed the facility to be free of odor, clean and in good repair. There are no bodies of water present. LPA toured the physical plant and observed the following:

KITCHEN: Appliances and fixtures were clean and functional. LPA observed seven day non-perishable and two-day perishable food supplies. Meals are prepared by the Staff. Knives and other sharps are locked inaccessible in a drawer. Kitchen and house cleaning supplies are stored in a locked cabinet. LPA observed a weekly menu to be posted.

COMMON AREAS: Common areas include the Living Room and Dining Room. All furniture was observed to be clean and in good condition, with enough seating for clients in care. There was space to accommodate both indoor and outdoor activities. LPA noted an Activity Calendar in the living room area and activities stored in the in the dining room area. The dining area was set up to celebrate resident 1’s (R1’s) birthday (R1).
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NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELIXIR CARE HOME
FACILITY NUMBER: 342701336
VISIT DATE: 03/20/2026
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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are within regulation. Both documents were observed to be complete and recently updated. Emergency disaster drill is conducted quarterly per regulation.

EXTERIOR: Exterior passageways were clean and clear of any obstructions. There is a backyard patio area for client and visitor use with furniture observed to be in good condition. There are no exterior gates.
BEDROOMS: LPA inspected facility bedrooms. The facility has five (4) total client bedrooms and (1) staff bedroom. All bedrooms were observed to contain furniture, bedding and linens within regulation. Extra linens are stored in the hallway cabinet. Client bedrooms had no visible hazards or inconsistencies observed.
BATHROOMS: There are three bathrooms. All bathrooms were observed to be clean and sanitary, and supplied with paper towels. Water temperature was tested and measured at 121.1 degrees F in the kitchen and 105 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation, S2 adjusted the water temperature during this visit to ensure water temperature is within 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time.
MEDICATION REVIEW: LPA reviewed medications which are centrally stored in a locked cabinet in the common area near the facility entrance. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. Fire drills are completed monthly. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. All emergency exits were clear from obstructions.

LPA requested client and staff files for review. LPA reviewed 6 resident files and 3 staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprinted and associated to the facility. Administrator holds certification Administrator Certificate # 7001763740 and expires on 11/10/2027.

The following documents were requested to be sent to the Regional Office:
(1) LIC 308 Designation of Administrative Responsibility
(2) Insurance verification
(3) LIC 610 Current Emergency Disaster Plan
(4) Surety Bond
(5) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is in compliance with Title 22 Regulation no deficiencies were cited. An exit interview was conducted with the Licensee, and a copy of these LIC 809 reports were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC809 (FAS) - (06/04)
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