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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340300556
Report Date: 09/07/2022
Date Signed: 10/05/2022 09:03:47 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2022 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20220831080437
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:
09/07/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Joe Jacques, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not have current training in first aid and cardiopulmonary resuscitation
INVESTIGATION FINDINGS:
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On 09/07/22 at 12:45, Licensing Program Analysts (LPAs) Renee Campbell and Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPAs met with Joe Jacques and explained the purpose of the visit. During this investigation, LPAs interviewed Staff1 (S1) and S2 Gary Kiesler. LPAs also reviewed staffing list provided by S1. Based on interviews and record reviews it was determined that Staff 3 (S3) and Staff 4(S4) have expired first aid and CPR certifications and Staff 5(S5) through S8 are missing first aid and CPR certifications.

As result, the above allegation is SUBSTANTIATED. An exit interview was conducted with Joe Jacques and a copy of this report was left with Joe Jacques. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220831080437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2022
Section Cited
CCR
82072(f)
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82072…. (f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from …….but not limited to, the American Red Cross. This regulation was not met as evidenced by:
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Licensee will submit scheduled staff training date for First Aid and CPR to LPA to POC due date. Licensee will provide proof of completed first aid and CPR certification to LPA no later 09/19/22.
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Based on interview and record review, it was determined that Staff 3 (S3) and Staff 4(S4) had expired first aid and CPR certifications and Staff 5(S5) through S8 were missing first aid and CPR certifications. This poses an immediate health and safety risk to residents in care.
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Licensee will provide a staffing schedule verifying that at least one staff member in classes and on transportation will be capable of providing direct care or supervision to clients and is first aid and CPR certified.
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
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