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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 11/06/2020
Date Signed: 11/06/2020 09:17:57 AM

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:COMMONS AT ELK GROVE, THEFACILITY NUMBER:
342700369
ADMINISTRATOR:COURTNEY HILLFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:110CENSUS: 91DATE:
11/06/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Courtney HillTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Suong Teh contacted the facility on this day via telephone to conduct a Case Management - Incident Visit. This visit was conducted by telephone in lieu of a physical visit due to the current COVID-19 precautions. LPA spoke with the facility Executive Director (ED) Courtney Hill and explained the purpose of the visit.

On 11/02/020 two incident reports were submitted to Community Care Licensing (CCL) from ED Courtney Hill. The reports stated that on 10/26/2020, @~0900 hours resident #1 (R1) missed his morning of Pregabalin. The report continue to report @~0900 hours resident #2 (R2) received an extra dose (1 tablet instead of 1/2 tablet) of a 15 mg morphine tablet.

Medication technician notified hospice nurse, R1’s and R2's families, R1's and R2's Primary Care Physicians and Community Care Licensing. Both residents were placed on status checks.

Medication policies and procedures were reviewed with the medication technician. The community has requested pharmacy provider for 1/2 tablets of the medication and uploaded new resident's profile in the electronic administration record (EMAR).

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the administrator was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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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