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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 08/26/2020
Date Signed: 08/26/2020 03:01:58 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:SIGNATURE LIVING ON LAVELLI WAYFACILITY NUMBER:
342700587
ADMINISTRATOR:ENERO, EDGARFACILITY TYPE:
740
ADDRESS:10125 LAVELLI WAYTELEPHONE:
(916) 812-0944
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
08/26/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Belinda Alagbate, CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Sabrina Calzada and Michael Hood met with Caregiver Belinda Alagbate to conduct a case management visit regarding recent relocation of resident "R1." LPAs wore M-95 masks upon entering facility and used hand sanitizer placed outside of facility. LPAs contacted Administrator Elnolito Llarenas via telephone and explained purpose of today's inspection. Administrator stated that Caregiver Alagbate may sign report for today's visit.

LPAs observed resident in his bedroom watching television. Resident stated that he was doing well. LPAs observed resident's bedroom and observed that he had the necessary accommodations in his room.

LPAs observed a 2-day perishable and 7-day non-perishable food supply at the facility. LPAs observed some unopened but unlocked insulin in refrigerator. LPA Calzada instructed insulin has to locked in a lockbox in the refrigerator or in a locked separate refrigerator. LPA Calzada instructed Administrator via telephone that insulin should be locked within 24 hours. Proof of locked insulin will be provided to assigned LPA Lund by COB tomorrow, 8/27/2020.

Caregiver stated that she had at least a 30-day supply of medications for resident. Caregiver stated that resident is adjusting well and facility will reach out to family with any concerns.

LPAs observed a sufficient supply of PPE, including gloves and masks. LPAs observed staff members wearing PPE.

There are no citation being issued at this time due to department being in technical assistance mode due to COVID-19 pandemic. Exit interview conducted. A copy of this report was provided to facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 243-4743
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
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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