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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004245
Report Date: 05/20/2021
Date Signed: 05/20/2021 02:46:37 PM

Document Has Been Signed on 05/20/2021 02:46 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:MAINLINE HOME CAREFACILITY NUMBER:
347004245
ADMINISTRATOR:MARRI EDQUIDFACILITY TYPE:
740
ADDRESS:9445 MAINLINE DRIVETELEPHONE:
(916) 690-8932
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator- Magnolia Tolon
Licensee - Aida Gatachalian
TIME COMPLETED:
02:50 PM
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On 05/20/21 at 1:25PM, Licensing Program Analysts (LPA) Christina Valerio and LPA Suong Teh arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with Administrator Magnolia Tolon and Licensee Aida Gatachalian and explained the purpose of the visit.

LPA Valerio and LPA Teh inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved during the visit. The facility has one central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. Staff are tested weekly for COVID-19. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designated and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 117° F in the bathroom and room temperature reads 75° F. LPA observed the facility to have adequate food supply. 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 extinguisher was up to date with last check on 03/10/21. Facility has a emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Licensee Aida and Administrator Magnolia.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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