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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701489
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:35:39 PM

Document Has Been Signed on 02/20/2025 12:35 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:CASA DORISFACILITY NUMBER:
342701489
ADMINISTRATOR/
DIRECTOR:		CLARK, BEATRICEFACILITY TYPE:
740
ADDRESS:8533 LIQUID AMBER WAYTELEPHONE:
(916) 670-0370
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 0DATE:
02/20/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Beatrice ClarkTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived announced on 2/20/25 at 10:30am and met with Applicant Beatrice Clark and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the facility that will be licensed and fire cleared for a capacity of 6 non-ambulatory residents. Administrator certificate expires on 10/30/25. LPA observed that the facility has submitted an Infection Control Plan. Facility is fire cleared for rooms 1-4 for Non-ambulatory residents.
LPA and Beatrice Clark 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 area in garage. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 115.7 *F which is within the required range of 105-120*F. The temperature inside the facility measured at 76*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 doors in the home. Facility has central heating and air. LPA observed the area where the staff and resident files will be locked and readily available for review.

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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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