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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701339
Report Date: 05/24/2024
Date Signed: 05/24/2024 09:54:44 AM

Document Has Been Signed on 05/24/2024 09:54 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:CARE HOME PARTNERSFACILITY NUMBER:
342701339
ADMINISTRATOR/
DIRECTOR:
LABIOS, JENNIFERFACILITY TYPE:
740
ADDRESS:10019 WATERFIELD DR.TELEPHONE:
(916) 667-9147
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 0DATE:
05/24/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH: Rosalia Debellis, Jennifer LabiosTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived announced to the facility to conduct a pre-licensing inspection. LPA met with Licensee Rosalia Debellis and Jennifer Labios.

The facility will be a Residential Care for the Elderly. It has been fire cleared to serve a maximum of 6 individuals, of which only 4 may be non-ambulatory, only 1 bedridden, and 1 ambulatory. The facility has an approved Dementia Care Program. The facility has an approved hospice waiver for two (2) hospice resident. Jennifer Labios has an active administrator certificate, #7019969740, expiration date 11/05/2025. LPA Valerio reviewed the facilities infection control plan and their emergency disaster plan.

LPA Valerio and licensee toured the facility. LPA Valerio inspected 5 bedrooms. Bedrooms were observed to be fully furnished. There will be no live-in care staff present at the facility. Two (2) bathrooms were observed to be fully stocked with skid mats, hand rails, shower chair, hand soap, paper towels, toilet paper, and a trash can. Hot water was measured and met Title 22 requirements. The kitchen was observed to have appliances that were in good repair and working condition. The pantry was stocked with canned goods that were dated and organized. The cabinets used for cleaning supplies, medications, resident records, staff records, and toxins were labeled and locked. A fire extinguisher was observed near the front hallway. Carbon monoxide detectors and smoke detectors were tested and observed to be in working condition. The exterior area was observed to have a shaded area for sitting, a grass area, and a shed for storage. The exit way located on the left side of the home was observed to be clear and fenced with a self-latching gate.

LPA Valerio, Licensee, and Administrator Jennifer went over CDSS website, Guardian, and facility records. Component III was completed with the licensee. Licensee Rosalia and Jennifer had no further questions.

LPA Valerio to inform the CAB Analyst that the Pre-Licensing is complete and this facility has no deficiencies.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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