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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:03:44 AM

Document Has Been Signed on 10/02/2024 11:03 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:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR/
DIRECTOR:		DAY, EDYLYNE JOHANNAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 2DATE:
10/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Edylyne Johanna Day TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived at the facility to conduct an announced pre-licensing visit. LPA and LPM met with Administrator/Licensee Edylyne Johanna Day, and explained the purpose of the visit.

The facility has a fire clearance for 4 non-ambulatory and 2 ambulatory residents. Bedrooms 1, 2, and 3 are approved for non-ambulatory residents. Bedroom 4 is approved for ambulatory only.
 
LPA, LPM, and Administrator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The facility is a 4-bedroom, 2 bath with 2 living rooms, 2 dining room, laundry room, kitchen, garage, and exterior area. Bedroom 1 and 4 are shared bedrooms, Bedrooms 2 and 3 are private rooms. The exterior area has a large cemented walk way, garden area, a shaded visiting area, and no obstructions to emergency exits. The fence was observed to have a self latching gate. Residents will have access to all area except garage, medication storage area, and locked cabinet storage for cleaning supplies and sharps. LPA observed no obstruction of emergency exits inside or outside of facility. LPA observed smoke detectors and carbon monoxide detectors were noted and functioning properly. The last fire drill was conducted 07/24/2024. LPA observed the area where the staff and resident files will be locked and readily available for review. LPA observed one (1) resident file and (1) staff file. LPA Valerio and licensee observed the hot water temperature in resident's bathroom at 110.1*F, within regulatory range of 105 *F and 120 *F. LPA observed food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Valerio observed a fire extinguisher in place outside of kitchen area and fully charged and within compliance.


Continues on LIC 809 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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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: SENIOR GUEST HOME
FACILITY NUMBER: 342701508
VISIT DATE: 10/02/2024
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Continued from LIC 809

The following deficiencies were observed:
- Fence board in the backyard need to be secured and replaced on the right side.
- Nails sticking out on the fence located on both sides need to removed
- Bathroom sinks, shower floors, and faucets need to be cleaned and free from mildew and hard water deposit.
- Wooden base board under the sink in the common area bathroom needs to be fixed
- Pee pads need to be removed from chairs in common areas and resident bedrooms
- Lock on snack cabinet need to be removed
- Ramps located outside of non-ambulatory rooms need to be secured
- Shoelace attached to fan in the primary bedroom needs to be replaced
- Bedroom 1 needs to have a ramp located outside the screen door
- An updated facility sketch needs to be submitted

Component III was completed during the visit with Administrator Edylyne Johanna Day.

Pre-Licensing is incomplete with deficiencies to be resolved by10/14/2024. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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