<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700428
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:43:22 PM


Document Has Been Signed on 10/17/2023 12:43 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:EKANEM, UWEM IMEFACILITY TYPE:
740
ADDRESS:10609 CHARBONO WAYTELEPHONE:
(916) 754-2899
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 5DATE:
10/17/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Sherry AhujaTIME COMPLETED:
01:00 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
On 10/17/23, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced case management visit to this facility. Community Care Licensing (CCL) called this facility and received an automated response stating that the number could not be completed as dialed. When CCL called the Designated Facility Administrator of record, an automated response would take a message but calls were not returned.

Upon arrival, LPA identified herself, the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA was met by Sherry Ahuja an dwas informed that there had been a change of ownership (CHOW) and that she and her husband had purchased the business as of September 1, 2023. LPA consulted with the previous LPA and was informed that the Licensee/Administrator of record did inquire by email what the process was for a change or ownership, however they did not alert CCL that they had decided to sell the business.

Sherry Ahuja, provided this LPA with the signed contract prepared by a business realtor for CCL to review. She also contacted the Licensee/Administrator of record to request an updated LIC 308 indicating her as the Designee for this facility while the CHOW is being processed.

LPA requested the LIC 500, and compared it to the Guardian roster. 1 out of 2 staff present at the facility had not received their criminal background clearance. LPA informed Sherry Ahuja that the uncleared worker needed to leave the premises and could not return to work until their background check returned stating that they were cleared. Sherry Ahuja called a replacement worker in to assist with the care of residents.

LPA conducted a brief tour of the facility and spoke with 5 out of 5 residents in care.

LPA requested the following documents:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 10/17/2023
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
26
27
28
29
30
31
32
LIC 500
Resident Roster
(2) complete resident files (R1 and R2)
Contract pertaining to the sale of Elizabeth Care Homes 1
LIC 200
Updated LIC 308

A Civil Penalty was issued for the deficiency observed today and is located on the
LIC421BG.

A copy of this report was provided along with Appeal Rights.

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

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/17/2023 12:43 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: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2023
Section Cited
CCR
87355(f)

1
2
3
4
5
6
7
87355(f) Criminal Record Clearance. An immediate civil penalty of $100 a day shall be assessed if an individual subject to a criminal record review has not obtained a clearance or exemption. (Maximum or 5 days.)
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall immediately have S1 undergo a criminal background check and have S1 cease working until a clearance is obtained. Administrator will follow-up with LPA via email at kimberly.viarella@dss.ca.gov by 10/19/23 and notify when S1 has obtained clearance and is associated to the facility.
8
9
10
11
12
13
14
Based on observation and record review, the licensee/facility failed to ensure S1 has a criminal record clearance. S1 has been employed since 10/01/23. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3