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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 11/04/2024
Date Signed: 11/04/2024 11:21:56 AM

Document Has Been Signed on 11/04/2024 11:21 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, THEFACILITY NUMBER:
342700369
ADMINISTRATOR/
DIRECTOR:		MEGGIN CORTEZFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 110CENSUS: 85DATE:
11/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Meggin CortezTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit.

On September 18, 2024, LPA Moleski received five incident reports which described incidents which had occurred at this facility more than seven days prior to that date. On September 19, 2024, Cortez informed LPA Moleski that these reports were submitted late.

One incident report described a resident (R1) suffering dizziness and nausea on 9/5/24. A second incident report described a resident (R2) suffering an unwitnessed fall on 8/25/24. Another incident report described a staff member finding a different resident (R3) on the floor in their bathroom after an unwitnessed fall on 9/4/24. A follow up incident report described the same resident (R3) being sent out to the hospital after continued disorientation after their unwitnessed fall on 9/4/24. The fifth incident report described an unwitnessed fall suffered by a resident (R4) on 8/24/24.

22 CCR Section 87211 requires written reports to be submitted within seven days of the occurrence of reportable events, such as resident injuries suffered while in the facility, or any incidents which threaten the welfare, safety, or health of any residents.

This facility is hereby cited per 22 CCR Section 87211(a)(1). An exit interview was held with Cortez. Appeal rights and a copy of this report was left with Cortez.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 11:21 AM - It Cannot Be Edited


Created By: Vincent Moleski On 11/04/2024 at 11:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE
FACILITY NUMBER: 342700369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited

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“(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…” This requirement was not met as evidenced by:
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Based on record review and interview, multiple incident reports were not sent to the Community Care Licensing Division within the required seven-day timeline, which poses a potential health, safety, and/or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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