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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700955
Report Date: 03/07/2022
Date Signed: 03/16/2022 07:07:31 AM

Document Has Been Signed on 03/16/2022 07:07 AM - 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ELITE ELDER CAREFACILITY NUMBER:
092700955
ADMINISTRATOR:GERGI, EDUARDFACILITY TYPE:
740
ADDRESS:2041 BATES CIRTELEPHONE:
(916) 941-6891
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 6DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eduard GergiTIME COMPLETED:
10:30 AM
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Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Eduard Gergi.

A review of staff records on 3/7/22 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies. However, 3 technical advisories were issued.

Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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