342700507-6-19-2026-27-AS-RJAY-DV7VS9-20260619164110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 06/19/2026
Date Signed: 06/19/2026 04:41:39 PM

Document Has Been Signed on 06/19/2026 04:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	LEXIE RAE'S CARE HOME		FACILITY NUMBER:	342700507
ADMINISTRATOR/ DIRECTOR:	RODRIGUEZ, ANNIE LYN		FACILITY TYPE:	740
ADDRESS:	8818 SHARKEY AVE		TELEPHONE:	(916) 714-0853
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6		CENSUS: 6	DATE:	06/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Administrator RODRIGUEZ, ANNIE LYN		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/19/2026, Licensing Program Analyst (LPA) Reza Jamaly and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced at this facility to conduct required 1 year visit. LPA met with the Staff 1 (S1) Marvin Rodriguez and stated the purpose of the visit. Administrator (A1), Annie Lyn Rodriguez later arrived and assisted with facility tour. There were 6 residents in care, 5 present and 1 in hospital with 2 staff on duty. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in Room 3, Hospice waiver granted for three but there is only one resident on hospice in Room 4. During this visit Administrator certificate was observed to be expired on 6/2/2025 per, administrator application for renewal submitted on March 25, 2025 but no update has been received as of today. LPM sent an email to Administrator Certification Bureau to follow-up on the application status since the A1 provided proof to LPM and LPA that the application was submitted with a check in the amount of the required fee. LPA and LPM toured the facility including but not limited to the common areas, kitchen, dining area, resident's bedrooms, bathrooms, laundry room and outdoor ground of the facility to ensure compliance with Title 22 regulations. LPA and LPM observed the facility to be free of odor, clean and in good repair. LPA and LPM observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA and LPM toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Refrigerator temperature was measured 30 degree Fahrenheit and Freezer temperature measured to be 20 degrees which is not in range of below 0 Degree as outlined in regulations. LPM observed one head of cauliflower in a plastic wrap to have beginning stages of mold on it. LPM asked facility staff to discard the item immediately and staff threw away the item immediately. Hot water temperature measured 111.7 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. Hot water temperature measured 109.4 degrees in common area bathroom sink, which was within required range as well. Room temperature during this visit was measured at 71 degrees Fahrenheit. Continues on LIC 9099C on page 2.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEXIE RAE'S CARE HOME	FACILITY NUMBER: 342700507
	VISIT DATE: 06/19/2026

NARRATIVE

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Grab bars and non-slip mat were observed to be stable and in good repair at this time.
Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in hallway and was last serviced on March 2026.

A tour of the dining area, living area, and all other areas intended for resident use was conducted.

Medication cabinet was observed to be locked in the office area of the facility and inaccessible to the residents at this time. LPA and LPM checked the medication of 2 out 6 residents. MAR for R1 was checked, it was learned that the month of medication being administrated was not recorded on the form. A Technical Advisory was issued.

A tour of 4 of 4 resident bedrooms and 2 of 2 restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in the resident hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.

First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted and found to be in good repair at this time.

LPA and LPM conducted file reviews of 3 out 6 residents.

Continues on LIC 9099C Page 3.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEXIE RAE'S CARE HOME	FACILITY NUMBER: 342700507
	VISIT DATE: 06/19/2026

NARRATIVE

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A review of (3) facility resident files was conducted and noted on the following LIC 858.
A review of (2) facility personnel files was conducted and noted on the following LIC 859. Both staff reviewed are associated to this facility and have current 1st aid/CPR certificate.
LPA observed the approved plan of operation and infection control plan to be present at the facility.

During this visit, 2 residents were watching TV at the living room, 3 residents were in their bedroom and one resident was on hospital.
The following forms and documents were obtained during this visit:

LIC 308 - Designation of administrative responsibility
LIC 409 - Administration organization
LIC 500 - Personnel report
LIC 610E - Emergency Disaster Plan

As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Annie and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2026 04:41 PM - It Cannot Be Edited

Created By: Reza Jamaly On 06/19/2026 at 04:16 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEXIE RAE'S CARE HOME	FACILITY NUMBER: 342700507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above, LPA observed a head of cauliflower which was moldy, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2026
	Plan of Correction
1 2 3 4	Staff will check the perishable food daily in refrigerator to make sure they are fresh and healthy to the resident.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC809 (FAS) - (06/04)

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