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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300556
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:28:48 PM

Document Has Been Signed on 12/13/2021 01:28 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: DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Agusta Osayande and Joe Jaquez TIME COMPLETED:
01:23 PM
NARRATIVE
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On 12-13-21 at 9:28am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a facility reported incident for client1 (C1) on 12-1-21. LPA met with Program Director Augusta Osayande and Executive Director Joe Jaquez and explained the purpose of the visit. LPA interviewed program director and reviewed incident report for C1 with program director. LPA also reviewed C1's physician order, staff training records, and health care plan for C1. LPA also interviewed Staff1 (S1) and S2. Based on interviews and record review, it was determined that due to tardiness of outside nursing agency who regularly assist C1 for medication needs, C1 received prescribed medication after departure from facility and should have received medication prior to departure. As a result, facility did not ensure C1s medical services were met efficiently.

Based on today's visit, deficiencies are cited under Title 22, Division 6, Chapter 3. An exit interview was conducted with Joe Jaquez and a copy of this report was left with Joe. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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 12/13/2021 01:28 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/13/2021 at 12:01 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELK GROVE ADULT COMMUNITY TRAINING, INC.
FACILITY NUMBER: 340300556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2021
Section Cited
CCR
82075(a)

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Health Related Services (a)The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for
and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee will develop and submit a plan to ensure all clients in care receive medication and other medical needs, which will include but not limited to: Procedures to follow in the event outside agencies are unable to assist with medical needs as necessary. Plan to be submitted to LPA by POC due date.
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Based on interviews and record reviews, licensee did not ensure C1 received prescribed medication on time after realizing tardiness of outside nursing agency. This poses a potential health and safety risk to clients in care.
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Licensee will conduct or arrange for staff training for C1s specific medication needs and provide scheduled training date and proof of completed training to LPA by POC due date.
Type B
12/23/2021
Section Cited
CCR82065(f)

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Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience providing knowledge of and skill...as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:
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Licensee will schedule required regulatory training for all staff per regulation 82065(f) and submit scheduled training date and proof of completed training to LPA by POC due date.
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Based on interview and record review, S1 and S2 did not receive all required training per regulation 82065(f) 1-9. This poses a potential health and safety risk to clients in care.
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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