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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701514
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:07:16 AM

Document Has Been Signed on 10/17/2024 11:07 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 HOME 2FACILITY NUMBER:
342701514
ADMINISTRATOR/
DIRECTOR:		CALDEIRA, MARIA SOCORROFACILITY TYPE:
740
ADDRESS:8667 SUMERLIN CT.TELEPHONE:
(916) 304-3575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Maria CaldeiraTIME VISIT/
INSPECTION COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived announced to conduct a pre-licensing inspection. LPA Valerio met with Administrator Maria Socorro Caleira and Licensee Ericson Serrano, and explained the purpose of the visit.

The facility is currently undergoing a Change of Ownership. LPA observed four (4) residents in care. LPA learned the residents are scheduled to move out by the end of the month. Maria Socorro Caldeira will be the designated Administrator. Administrator Certificate # 60733007740 expires on 09/24/26. The facility has an approved fire clearance for six (6) non-ambulatory residents for bedrooms #1, #2, and #3. There is a separate sleeping area designated for staff only. The facility has a granted hospice waiver for three (3).

LPA Valerio reviewed the infection control plan and their emergency disaster plan. LPA Valerio observed the physical plant to ensure compliance with Title 22. LPA observed the common areas to clean, organized, and free from debris. Areas were observed to be fully furnished. LPA Valerio observed resident bedrooms to be equipped with beds, clean linens, a dresser, night stand, closet space, a chair, and a lamp. Resident bathrooms were stocked with hygiene supplies, hand soap, paper towels, a lidded trash can, a skid mat, shower chair, and hand rails. Bathrooms were observed to be clean. The backyard was observed to have areas for outdoor activities. Emergency exits were clear of obstructions. Medications, sharps, chemicals, and cleaning supplies were observed to be locked and inaccessible to residents in care. LPA observed were the files will be maintained.

LPA Valerio conducted Component III with Licensee Ericson and Administrator Maria. There were no further questions from either the licensee or Administrator. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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