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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701436
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:04:04 PM

Document Has Been Signed on 09/24/2024 05:04 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:RANCHO RESIDENTIALFACILITY NUMBER:
342701436
ADMINISTRATOR/
DIRECTOR:		MENDOZA AILEEN MAEFACILITY TYPE:
740
ADDRESS:12057 ALERIATELEPHONE:
(916) 619-7896
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 6CENSUS: 0DATE:
09/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Tony Hoang and Aileen MendozaTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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On 9/24/24, at 2pm, Licensing Program Analyst (LPA), Arvin Villanueva conducted an announced inspection to the above facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 3/22/24, for an Initial license for a Residential Care for the Elderly. The requested capacity is for 6 residents. LPA was greeted and accompanied on inspection by the applicants, Tony Hoang and Aileen Mendoza.

Facility is a single-story house located in a newly developed residential neighborhood. Facility has 6 single occupancy resident bedrooms and 3 full bathrooms. Resident bedrooms are located on the left side of the facility and right side are the garage, laundry, kitchen, living and dinning room.

Outdoor Area: There is a covered patio going to the backyard. At this time it is not equipped with outdoor furniture. The backyard lawn bare and is not developed at this time. Per applicants, they plan to landscape in the future. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Fence and gates are new and in good repair. No swimming pools/bodies of water at this time. Per applicants, they will not be adding bodies of water to the property.

Residents' Bedrooms: LPA observed 6 resident bedrooms. The resident bedrooms are spacious and will easily accommodate the resident's furnishings. All bedrooms are fire cleared for bedridden residents. The facility is equipped with sprinkler system and each bedroom is equipped with sprinklers. 1 of 6 bedrooms (labeled owner's suite in the facility sketch) is fully furnished at this time. The other bedrooms are in the process of being furnished. Per applicants, they plan to accept residents who might be needing hospital beds.

{Con't on LIC809-C}
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: RANCHO RESIDENTIAL
FACILITY NUMBER: 342701436
VISIT DATE: 09/24/2024
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Bathroom: Facility has 3 resident bathrooms. 1 of 3 bathrooms is in the 1 bedroom (labeled owner's suite in the facility sketch). All bathrooms have working toilets, wash basins and full baths with showers. All bathrooms are equipped with non-skid flooring and close-lid garbage bins. LPA did not observed grab bars in the bathrooms. Per applicants they will be installing grab bars. LPA observed adequate lighting in hallways leading to bathrooms.

Linens & Hygiene Supplies: Adequate supply of linen and hygiene supplies stored in linen closet, which is at end of the hall between the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu: The facility will utilize google voice via laptop for resident use. Emergency Disaster Plan will be posted & available for review on the wall. One fully charged fire extinguisher were found in hallway located in the kitchen/dining room. Fire extinguisher was last serviced on 7/10/24.

Toxins: Toxins locked/stored under kitchen sink and in the laundry area and are inaccessible to residents.

Water temperature: Hot water temperature was measured at 117*F in 1 of 3 bathrooms.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked drawers.

Smoke Detectors and carbon monoxide: Facility has smoke detectors/carbon monoxide monitor combination. LPA observed one in each resident bedrooms and in the foyer and in the kitchen/dining room/living room area.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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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: RANCHO RESIDENTIAL
FACILITY NUMBER: 342701436
VISIT DATE: 09/24/2024
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Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the regulatory temperature for food storage. Washer and dryer are located in the laundry room.

Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen area, available for staff use but inaccessible to residents.

Residents & Staff Files: Applicant will not be handling cash resources of residents at this time but will submit necessary documents for any changes.

Reading Material, Games, Equipment & Materials: During this visit, activity materials are not available at this time. Outside activity area is properly enclosed. LPA did not observed outdoor furniture at this time. LPA did not observed television for residents use at this time.

Component III: Pre-licensing is not complete at this time. According to the applicants, they are not ready to finish the pre-licensing and component III at this time. Per applicants, they will be ready to resume the pre-licensing on 11/8/24.

An exit interview was conducted with and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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