342700369-7-19-2021-27-AS-CYAG-C53VGZ-20210719162620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 06/30/2021
Date Signed: 07/19/2021 04:26:26 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:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	COURTNEY HILL		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(916) 683-6833
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS: 84	DATE:	06/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Liza Spencer		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility by LPA Yang and LPA Hubbard on 06/30/2021 and were met by the Director of Resident Services, Liza Spencer, who was briefly interviewed. It was learned that there were (2) residents currently receiving services through home health as well as (2) residents under the care of hospice at this time. This facility is cleared to accept and be able to retain up to (10) hospice residents at any given time. Current census was 84 residents. Tour of this facility was conducted. Common areas on the first floor were toured. Living room, dining room, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 12/07/2020 by the local fire authority and in compliance at this time. Kitchen area was toured. Food storage units were reviewed and observed to be set and regulated to the proper temperatures at this time. Food supply for 2-day perishable and 7-day non perishable quantities were observed to be present and in compliance at this time. A sample of the resident bedrooms were toured. Bedroom furniture and furnishings were observed to be in good repair and sufficient to meet the needs of the residents at this time. This LPA activated the emergency pull cord in a resident room to gauge the response time of facility staff. A sample of the resident restrooms were toured. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time. Laundry room was toured. Cleaners, cleaning agents, and laundry supplies were observed to be locked and made inaccessible to the residents at this time. Medication room was toured. Policies and procedures were discussed with the medication technician who was present on ordering, documenting, and dispensing of the medications unto the residents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

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: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 06/30/2021

NARRATIVE

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First aid kit was observed to be present and contained all of the necessary components at this time.
Memory Care unit, Connections for Living, was toured. A sample of the resident bedrooms and restrooms were toured.
Enclosed courtyard area for the memory care unit was toured.
Exterior grounds for this facility were toured. Perimeter fence, side gates, and exterior exits were reviewed.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC809 (FAS) - (06/04)

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