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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:16:55 PM


Document Has Been Signed on 03/18/2024 01:16 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:COMMONS AT ELK GROVE, THEFACILITY NUMBER:
342700369
ADMINISTRATOR:MEGGIN CORTEZFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:110CENSUS: 89DATE:
03/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Meggin CortezTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit.

LPA Moleski reviewed a death report describing a resident's (R1's) death on 3/12/24. The cause of death was unknown, according to the death report.

LPA Moleski interviewed Cortez and four staff members (S1-S4) and reviewed resident 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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