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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701507
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:12:22 AM

Document Has Been Signed on 10/21/2024 11:12 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:SUMERLIN GUEST HOMEFACILITY NUMBER:
342701507
ADMINISTRATOR/
DIRECTOR:		SERRANO, ERICFACILITY TYPE:
740
ADDRESS:8671 SUMERLIN CTTELEPHONE:
(916) 304-4357
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Eric SerranoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 10/21/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA Villanueva met with Administrator Eric Serrano, and stated the purpose of the visit.

Present during today's visit were 4 residents in care with 2 staff on duty.

During this visit, LPA obtained copy of resident files (R1, R2, R3, and R4), including their Identification and Emergency Information, Pre-Placement Appraisal Information, current Physician Report and current Needs and Services Plan. Per Administrator, current residents are not currently receiving outside agency services.

No deficiencies are being cited during today's visit.

Exit interview was conducted with Eric Serrano and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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