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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:38:54 AM


Document Has Been Signed on 06/02/2022 11:38 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 83DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Meggin Cortez - AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection Visit for facility. LPA was met by Administrator and purpose of visit was explained. This facility is cleared to accept and be able to retain up to (15) hospice residents at any given time. Administrator Certificate 6051691740 Expires 04/08/2023.
LPA and Administrator conducted physical plant inspection. Common areas on the first floor, 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 expire on 12/02/2022 have been inspected by the local fire authority and in compliance.
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.
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.
A sample of the resident restrooms were toured. Hot water temperature was measured at 108.2 F which was within the allowed range of 105-120 degrees. Grab bars and non-skid mats/surfaces were observed to be present and in good repair. 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.
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 observed.
There were no deficiencies observed or cited during today's annual visit.
Exit Interview held with Administrator and copy of report left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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