<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000917
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:24:02 PM


Document Has Been Signed on 08/22/2024 01:24 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ELIM WOODSFACILITY NUMBER:
317000917
ADMINISTRATOR:LEE, JENNIFER E.FACILITY TYPE:
740
ADDRESS:8894 LITTLE CREEK DR.TELEPHONE:
(916) 791-8022
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Farah CucciaTIME COMPLETED:
12:45 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 8/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with caregiver and explained the purpose of the visit.

Assistant Administrator arrived to the facility after tour was completed.

Today's census is six residents with one on hospice services, facility is licensed for six non-ambulatory hospice waiver of two.

LPA and Caregiver conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four resident bedrooms, two bathrooms, laundry room, dining room kitchen and the common areas. LPA observed presence of fire extinguisher to be present with service date of April 29, 2024. LPA observed the facility to have the required poster posted in the hallway. LPA observed facility to have 2 days of perishables and 7+ days of non perishable foods present for residents in care. LPA observed sharps, toxins, and medications to be locked and inaccessible to residents. LPA observed five residents in the dining room and one resident watching television in the common areas.

LPA conducted a full file review of facility's Medication Administration Record and facility's Centrally Stored Medication Record. Medication count was conducted with Assistant Administrator.

File review conducted for six residents records.

LPA completed the CARE inspection tool and no deficiencies cited.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1