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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003782
Report Date: 01/06/2023
Date Signed: 01/06/2023 12:26:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/06/2023 12:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FOUR SEASONS HOME CARE 2FACILITY NUMBER:
347003782
ADMINISTRATOR:SAVIN, DOINAFACILITY TYPE:
740
ADDRESS:9093 QUAIL TERRACE WAYTELEPHONE:
(916) 685-9806
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Doina Savin, AdministratorTIME COMPLETED:
12:30 PM
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On 01/06/2023 at approximately 9 am, Licensing Program Analyst Renee Campbell conducted an unannounced annual inspection on this date. LPA met with Administrator and staff and explained the purpose of the visit.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers were inspected on 12/07/2022 and smoke detectors were tested and found to be in compliance with fire safety. Carbon dioxide monitor present and functioning. LPA observed centrally stored medications locked inside the medication cabinet. LPA and Administrator reviewed 3 staff files, including criminal record clearances. All staff today are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Fire drill was completed on 11/23/2022 .

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, No deficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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