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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701511
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:18:41 PM

Document Has Been Signed on 10/18/2024 03:18 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:ELDERLY GUEST HOMEFACILITY NUMBER:
342701511
ADMINISTRATOR/
DIRECTOR:		SERRANO, ERICFACILITY TYPE:
740
ADDRESS:8774 KELSEY DRIVETELEPHONE:
(916) 304-3575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
10/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Eric SerranoTIME VISIT/
INSPECTION COMPLETED:
03:15 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
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/18/24 at 1:15pm and met with Applicant Elderly Guest Home Sarah Jane Egante and Administrator Eric Serrano 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 residents of which 4 maybe non-ambulatory. Rooms 1,5,6,7 can accommodate non-ambulatory residents and room 2 is for staff.

Administrator certificate expires on 8/26/26. LPA observed that the facility has submitted a Infection Control Plan. LPA observed a Designation of Facility Responsibility (LIC308) on file.

LPA and Sarah Jane Egante and Eric Serrano 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 and bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 113.8 *F which is within the required range of 105-120*F. The temperature inside the facility measured 72*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). Facility also has central heating and air.

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: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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