<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:22:02 PM

Document Has Been Signed on 10/21/2024 02:22 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:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR/
DIRECTOR:		DAY, EDYLYNE JOHANNAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(702) 629-0201
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 1DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marie Walker, DesigneeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/21/24, Licensing program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to speak with the Designated Facility Administrator, Edylyne Johanna A Day (certificate # 6070622740, expiration date 05/28/26). The Administrator was not present but the LPA spoke to her on the phone and obtained permission for the Caregiver/ Designee, Marie Walker. to sign on her behalf.

LPA collected the following documents for the resident in care (R1):
LIC 602A
LIC 625
LIC 601
LIC 603

LIC 308 to be updated and faxed to Community care Licensing by the close of business on 10/21/24 at (916) 263-4744.

According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
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)
Page: 1 of 1