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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 03/11/2021
Date Signed: 03/11/2021 03:11:24 PM

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:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR:CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:10CENSUS: 10DATE:
03/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Edna CleggTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck made an unannounced case management televisit to this facility due COVID-19 Pandemic safety provisions. LPA spoke with Licensee Edna Clegg on 03/11/2021. LPA explained the purpose of this visit is to follow up on an incident in reference to complaint#27-AS-20200820101846.

During the course of the investigation of the complaint mentioned above, LPA determined the facility did not meet timely reporting requirements for reporting of resident death.

Deficiencies are cited from California Code of regulations, Title 22, Division 6. 1 citation is listed on the attached LIC809D. If the deficiency is not corrected by the noted due date civil penalties may be assessed.


Exit interview was conducted with Licensee. Copy of the report sent to Licensee via e-mail
with a "read receipt" to verify the LIC 809, LIC 809-D, and appeal rights were received. Licensee is to
print out each report, sign it, and send a signed copy to LPA at 916-263-4744
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2021
Section Cited

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87211 Reporting Requirements
(a) licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence. (A) Death of any resident from any cause regardless of where the death occurred. This requirement was not met as evidenced by
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Based on observation, interview the licensee
did not ensure incident reports were submited to licensing agency within the seven days of the occurence.
This poses an immediate health and safety code to persons in care.
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Licensee will submit certificate for proof of class completion to LPA via email within 30 days from date of citation. Licensee will submit copy of training log provided to staff on reporting requirements to LPA via email. Due date: 04/9/2021

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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 RichardsonTELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2021
LIC809 (FAS) - (06/04)
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