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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300556
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:08:55 PM

Document Has Been Signed on 04/06/2023 01:08 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:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joe JaquezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 4/6/23 at approximately 10am Licensing Program (LPA) Analyst Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Executive Director Joe Jacquez and explained the purpose of today's visit.

LPA Jensen toured the grounds and interior of the facility. All exterior paths were observed to be clear of obstruction. The facility was observed to be sanitary and free of odor. The facility consists of offices, classrooms, bathrooms, changing rooms and various storage areas. The fire extinguisher was last serviced in December of 2022 and is in compliance. The last fire drill was completed in January of 2022. The first aid kit was complete with scissors, tweezers, thermometer, various wound dressings and manual. The facility has emergency lighting and an adequate supply of PPE. The Emergency disaster plan was reviewed and is in compliance. The Emergency disaster plan was last updated in February of 2023. The thermostats were set at 68-70 degrees and are within the required range of 68-85 degrees Fahrenheit. The facility has laundry room on site. All appliances were observed to be in good working order. During the course of the visit LPA Jensen interacted with several clients who were engaged in a variety of activities. All residents were observed to have their needs met and were actively pursuing their interests. LPA Jensen observed three separate classroom/kitchen areas that had cleaning supplies or chemicals that were not locked and accessible to clients. The accessible products included dishwashing pods, disinfectants and bleach, photos were taken. All medications were observed to be locked and inaccessible to clients. All knives were observed to be locked and inaccessible to clients. The inspection tool was used during the course of this visit. 5 Resident files were reviewed and 5 staff files were reviewed and in compliance.

Deficiencies are being cited from California Code of Regulations (CCR) and Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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 04/06/2023 01:08 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/06/2023 at 12:48 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: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observations and an interview with the Executive Director, Joe Jacquez], the licensee did not does not maintain carbon monoxide detectors at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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The Licensee agrees to equip the facility, including all classrooms with carbon monoxide detectors by the Plan of Correction of due date. Licensee will email LPA Jensen at maja.jensen@dss.ca.gov photos of the installed carbon monoxide detectors.
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observations the licensee did not comply with the section cited above in 3 counts out of 5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee agrees to immediately lock all cleaning cupplies and chemicals and to conduct an inservice training with staff. Licensee agrees to email an attestation to maja.jensen@dss.ca.gov.
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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
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