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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700088
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:38:42 PM


Document Has Been Signed on 02/01/2024 12:38 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:NJ CARE HOMEFACILITY NUMBER:
342700088
ADMINISTRATOR:JAMES, MERLITAFACILITY TYPE:
740
ADDRESS:8200 WOODED BROOK DRIVETELEPHONE:
(916) 248-0652
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
02/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Merlita JamesTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a resident death report. LPA Moleski met with facility administrator Merlita James and explained the purpose of the visit.

LPA Moleski reviewed a death report for a resident (R1). R1 died at a hospital on January 26, 2024, according to the report. LPA Moleski reviewed R1's file. LPA Moleski interviewed James, a staff member (S1), and a R1's roommate (R2).

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with James.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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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