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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003884
Report Date: 11/18/2022
Date Signed: 11/18/2022 01:16:00 PM

Document Has Been Signed on 11/18/2022 01:16 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:TAHOE, THEFACILITY NUMBER:
347003884
ADMINISTRATOR:DESCARGAR, BERNADETTEFACILITY TYPE:
740
ADDRESS:8708 SECKEL COURTTELEPHONE:
(916) 686-5715
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bernadette Descargar - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA explained the purpose of the visit to administrator.. LPA was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days.
 
LPA and administrator inspected physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA conducted the infection control domain tool. The facility has an approved LIC 808 mitigation plan uploaded into FAS. The facility has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility.

LPA observed the temperature inside the facility was measured at 75*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 108.0*F in kitchen which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last serviced 2/3/2022.

LPA reviewed two (2) resident files and three (3) staff files. All staff are fingerprint cleared and have current first aid certificates. All residents have required documents for community care licensing (CCL).

 Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit.

An exit interview was held and a copy of the report was left with Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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