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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004245
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:39:12 PM

Document Has Been Signed on 03/29/2022 03:39 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: 5DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Aida GatchalianTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA explained the purpose of the visit and was met by Co-Administrator Magnolia Tolon
and Licensee Aida Gatchalian. Licensee and Administrator were observed to have their updated Administrator certificate posted at the front entry way.


LPA Valerio discussed recent PINs, and reviewed facility COVID tracking procedures. The facility common areas were free from debris and clean. Facility staff are said to clean multiple times per shift and every time common areas are used. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed throughout the facility. The common areas were clean and organized. During the visit, the facility was observed to be following all policies related to vaccinations, visitors, and the health and safety of the residents.

LPA Valerio and staff toured the physical plant inside and out to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. The backyard has a sitting area for family visits. LPA observed an emergency supply of food, water, and first aid supplies. Medication cabinet, cleaning supplies, sharps were locked away and inaccessible to residents in care. Hot water was measured at 112.2*F. Room temperature was set to 72*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Resident rooms were clean and organized. Fire extinguishers were observed to be charged and within compliance with last check on 03/10/2022.

LPA Valerio requested copies of the following to be sent to LPA by COB 04/04/2022: Administrator Certificates, LIC 308, LIC 610E, LIC 500, and Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with Licensee Aida Gatchalian.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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