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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700428
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:55:31 PM


Document Has Been Signed on 03/05/2024 04:55 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:ELIZABETH CARE HOMES 1FACILITY NUMBER:
342700428
ADMINISTRATOR:AHUJA, SHERRYFACILITY TYPE:
740
ADDRESS:10609 CHARBONO WAYTELEPHONE:
(916) 619-8100
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sherry AhujaTIME COMPLETED:
05:30 PM
NARRATIVE
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On 03/05/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Sherry Ahuja and a brief interview followed.

LPA began the inspection in the kitchen. LPA observed opened containers of pasta sauce and Alfredo sauce stored in one of the cabinets. These items should have been labeled with the date opened, and refrigerated afterward. LPA observed 2-day perishable and 7-day non-perishable food supply at this time. LPA also observed another refrigerator with additional food storage in the garage. LPA observed a bag of frozen chicken being defrosted in the sink. LPA provided information regarding proper defrosting and storage of food items.

Medication cabinet, located in the kitchen, was locked and made inaccessible at this time. The facility had additional medications in a cabinet in the living room. A review of the policies and procedures for dispensing, storing, and handling of the medications was discussed with staff.

Fire extinguisher, located in the kitchen area, was observed to have been annually inspected on 11/22/23 and in compliance at this time.

A tour of the 5 resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

Resident restrooms, 2 located in the hallway, were toured. Grab bars were observed to be functional and in compliance. Both bathrooms were missing paper towels. The DFA refilled the paper towel holders. Hot water temperature was taken and measured to make sure that they were within the allowed range of 105-120
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELIZABETH CARE HOMES 1
FACILITY NUMBER: 342700428
VISIT DATE: 03/05/2024
NARRATIVE
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degrees. The exterior grounds of this facility were oured. Perimeter fence, side gates, and latching mechanisms were reviewed. There were no outbuildings or bodies of water. LPA observed debris on both sides of the house: discarded tabletop, fence posts, and broken furniture. There were two screens in the front of the house that had holes and needed to be replaced.

A review of 3 resident files was conducted. Consent forms were missing along with a centrally stored medication destruction record for each. LPA provided the DFA with samples of these forms for future use. A review of 3 staff files was conducted. LPA found that 2 of the 3 files reviewed were missing Fingerprint Clearances and Health Screenings although all staff had proof of negative TB test results. LPA provided a sample of the Health Screening form to the DFA for future reference. Civil penalties were cited for the missing Fingerprint Clearances.

According to California Code of Regulations, Title 22, all deficiencies observed today were cited on the LIC809 D page and the LIC 421

A copy of this report was provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/05/2024 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ELIZABETH CARE HOMES 1
FACILITY NUMBER: 342700428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 ouf of 3 staff files where Health Screenings, training, and information from the LIC 501 was missing. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Administrator stated that all training will be concluded by the POC date and any missing materials from the staff files will be added by the POC date as well. These materials will be submitted to Community Care Licensing at kimberly.viarealla@dss.ca.gov by 04/02/24.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the LPA observed 2 opened jars of past sauce stored in a cabinet instead of being lanbeled when they were opened and stored in the refrigerator. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Administrator stated she will conduct an audit of all the food items in the cabinets and refrigerators to dispose of any expired items. The Administrator also stated she will conduct a training and post signage about proper labeling and storage of food. Administrator will submit pictures of the signs and signature sheet for all employees who attended the training. These items will be submitted to CCL at kimberly.viarella@dss,ca,gov
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 03/05/2024 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ELIZABETH CARE HOMES 1
FACILITY NUMBER: 342700428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the LPA observed 2 broken screens in the front of the house. LPA also observed discarded broken furniture and fence posts located on both sides of the house that also poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Administrator stated that the screens will be repaired and the debris on the side of the house will be removed by 04/02/24. Pictures will be submitted to kimberly.viarella@dss.ca.gov by 04/02/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 03/05/2024 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ELIZABETH CARE HOMES 1
FACILITY NUMBER: 342700428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
CCR 87355(e) All individuals subjec tto a criminal review pursuant to Health and Safety Code 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility ...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and a search in Guardian, the licensee did not comply with the section cited above in 2 out of 3 staff files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Administrator will be sending non-cleared employees to be live scanned tomorrow, 03/06/24 and will submit a receipt for each showing that this first step has been completed. Administrator understands that these employees may not work until they have been cleared and associated to this facility in Guardian.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7