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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300556
Report Date: 02/22/2022
Date Signed: 02/22/2022 12:34:44 PM

Document Has Been Signed on 02/22/2022 12:34 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:ELK GROVE ADULT COMMUNITY TRAINING, INC.FACILITY NUMBER:
340300556
ADMINISTRATOR:BRUBAKER, REBECCAFACILITY TYPE:
775
ADDRESS:8810 ELK GROVE BLVD.TELEPHONE:
(916) 685-7666
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 160CENSUS: 77DATE:
02/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Augusta OsayandeTIME COMPLETED:
12:55 PM
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On 2-22-22 at 12:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident which occurred on 2-14-22. LPA met with Program Administrator Augusta Osayande and explained the purpose of the visit. LPA reviewed incident report, facility's program design, staff training material, and interviewed program administrator. On 2-14-22, an incident occurred at the facility which required first aid attention for Resident1 (R1). Based on interview and record review, it was determined that a small amount of blood was noticed on R1's tube feeding site on 2-14-22. It was further determined that R1 was scratching the area which led to the bleeding, and blood was not coming out of the tube directly. Staff rendered standard first aid for R1 until R1 was picked up by responsible party. Staff present during the incident have current first aid and tube feeding training in place to recognize signs and symptoms of infection and emergency response. Tube was not separated from R1 during the incident and required only cleaning. No discomfort of R1 was observed based on interview and was back in program the following day. It was determined that appropriate response to this incident took place.

As a result of this case management visit, no deficiencies were cited. An exit interview was conducted with Augusta Osayande and a copy of this report was left with Augusta.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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