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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:29:19 AM

Document Has Been Signed on 10/03/2024 10:29 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:
10/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Edylyne Johanna Day TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a continued pre-licensing visit. LPA Valerio met with Administrator Edylyne Johanna Day, and explained the purpose of the visit.

On 10/02/2024, LPA received a phone call in the afternoon from Administrator stating the corrections have been completed.

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

Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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