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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700369
Report Date:
01/09/2024
Date Signed:
01/09/2024 10:42:42 AM
Document Has Been Signed on
01/09/2024 10:42 AM
- 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:
COMMONS AT ELK GROVE, THE
FACILITY NUMBER:
342700369
ADMINISTRATOR:
MEGGIN CORTEZ
FACILITY TYPE:
740
ADDRESS:
9564 SABRINA LANE
TELEPHONE:
(916) 683-6833
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95758
CAPACITY:
110
CENSUS:
83
DATE:
01/09/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Meggin Cortez
TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on two incident reports describing resident falls. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit.
The incident reports described an unwitnessed fall suffered by a resident (R1) on 12/4/23 and an unrelated fall suffered by another resident (R2) on 12/8/23.
LPA Moleski interviewed Cortez and a staff member (S1) who was present when R2 fell. LPA Moleski reviewed resident records and facility records.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
01/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/09/2024
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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