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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:04:23 PM


Document Has Been Signed on 04/05/2023 04:04 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 4DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Rod FleemanTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Melissa Parks and Lavinia Muscan arrived on Wednesday April 5, 2023 to conduct the annual inspection. LPAs wore surgical masks during today's inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (4) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training did not contain the required initial training, please see 809-D for deficiency.

LPAs and Administrator Rod Fleeman toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas. In the areas toured, there were no health or safety violations observed.

LPAs requested a copy of the LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report and appeal rights were printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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Document Has Been Signed on 04/05/2023 04:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: EL DORADO HILLS SENIOR CARE
FACILITY NUMBER: 097005554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of two staff training records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Facility to submit plan for new hire/initial training for new employees
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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