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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001715
Report Date: 06/03/2021
Date Signed: 06/03/2021 10:51:53 AM

Document Has Been Signed on 06/03/2021 10:51 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CARING FAMILIES-BV2FACILITY NUMBER:
347001715
ADMINISTRATOR:MICHELLE MACIASFACILITY TYPE:
740
ADDRESS:8716 BRAY VISTA WAYTELEPHONE:
(916) 686-0420
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
06/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle MaciasTIME COMPLETED:
11:00 AM
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On 06/03/2021 at 8:05am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator, Michelle Macias regarding facility risk assessment questions. Administrator confirmed no staff or residents have experienced symptoms within the last 10 days. At 9:20am, LPA Ashley Boothe and LPM Liza King arrived unannounced to conduct a required 1-year Annual inspection. LPA and LPM met with Administrator, Michelle Macias and explained the purpose of today’s inspection. LPA's was allowed entry into the facility that is licensed to serve a total capacity of 6 non ambulatory residents and LPA observed locked perimeter in compliance with fire clearance and license. Today's census is 6 of which 5 are non ambulatory and 0 Hospice Residents. Two of two staff observed with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 7/4/2022.

LPA interacted with a random number of residents during this visit and observed residents engaging in group activities, an activity calendar posted. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas to be clean in good repair. LPA observed items stored outdoors, Administrator stated they are awaiting pick up and gardener services. The temperature inside the facility was measured at 77*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 105.4 *F which is not less than 105 *F and not more than 120*F. LPA observed the centrally stored medications, knives, kitchen, laundry and staff restroom area to be locked inaccessible to residents. Three of three medications matched MAR, no missed or refused medications. All medications observed properly stored and labeled. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CARING FAMILIES-BV2
FACILITY NUMBER: 347001715
VISIT DATE: 06/03/2021
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LPA observed fire extinguisher last inspected on 2/5/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30 day supply of PPE stored.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate
Emergency Disaster Plan LIC610E
Liability Insurance
Health Screening Report-Facility Personnel LIC503
In-service Training Program
First Aid/ CPR certificates

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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