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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300556
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:28:10 PM

Document Has Been Signed on 03/29/2024 12:28 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ELK GROVE ADULT COMMUNITY TRAINING, INC.FACILITY NUMBER:
340300556
ADMINISTRATOR:JOE JAQUEZFACILITY TYPE:
775
ADDRESS:8810 ELK GROVE BLVD.TELEPHONE:
(916) 685-7666
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 160CENSUS: 56DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Augusta Osayande, Program DirectorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a required - 1 year visit on 3/29/24 at 8:30am and met with Augusta Osayande, Program Director and stated the purpose of the visit. The facility is licensed for a capacity of 160 clients of which 35 maybe non-ambulatory. Licensing fees are current. The most recent emergency/disaster drill was conducted on 1/25/24.

LPA and Augusta Osayande, Program Director toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA and Program Director observed paint thinner as well as other chemicals in a container outside one of the classrooms not locked during the tour. LPA observed there are clients participating in activities during this visit. LPA observed the kitchen area, activity areas, bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps areas to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 115.9*F which is within the required range of 105-120*F. The temperature inside the facility measured between 71-72*F in all classrooms which is within the required range of 68-85*F. LPA observed facility secures client monies for community activities which is documented and distributed weekly for those who can not manage their monies. LPA observed clients bring their own meals and snacks on a daily basis which is not provided by the facility.

As part of the curriculum the facility staff conducts basic life skill classes where the items that are prepared by the clients are consumed by the clients and staff. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and pull alarm system in the facility.

LPA observed 3 client and 3 staff files and conducted interviews during this visit. Facility has central heating and air. LPA observed area where the resident files are locked and readily available for review.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELK GROVE ADULT COMMUNITY TRAINING, INC.
FACILITY NUMBER: 340300556
VISIT DATE: 03/29/2024
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Upon a file review the following items were discussed to be submitted by fax with any changes annually:
Designation of Administrative Responsibility LIC308-Submit
Administrative Organization LIC309-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-Submit
Surety Bond LIC402-Submit
Personnel Report LIC500-Submit
Health Screening Report-Facility Personnel LIC503-NA
Criminal Record Clearances LIS536-NA
Emergency Disaster Plan LIC610D-Submit
Facility Floor Plan/Plot Plan LIC999-Current
Admission Policies and Procedures-Submit
Articles of Incorporation/Organization, Constitution and bylaws-Submit
Bacteriological Analysis of Private Water Supply-NA
Control of Property-Submit
Exemptions/Waivers and Exceptions-NA
Fire Clearance (consistent with terms and limitations of license)-NA
First aid/CPR certificates-NA
Infection Control Plan to include any addendums-Submit
In-service Training Program-NA
Job Description/Personnel Policies-Submit
Liability Insurance-(if applicable) Submit
Licensing fees-Current
Medication Procedures-Submit
Partnership Agreement-NA
Plan of Operation to include (Restricted Health Care Plan (if applicable))-Submit
Qualifications of Administrator/Facility Manager-NA
Transportation Procedures-Submit

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Program Director was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit Interview held and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2024 12:28 PM - It Cannot Be Edited


Created By: Victoria Brown On 03/29/2024 at 11:02 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)(A)


This requirement is not met as evidenced by:
LPA and Program Director observed chemicals in a container that was not locked during the tour.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2024
Plan of Correction
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Licensee shall ensure all chemicals are locked at all times.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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