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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:20:40 PM


Document Has Been Signed on 10/03/2024 01:20 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:SIGNATURE LIVING ON LAVELLI WAYFACILITY NUMBER:
342700587
ADMINISTRATOR:ENERO, EDGARFACILITY TYPE:
740
ADDRESS:10125 LAVELLI WAYTELEPHONE:
(916) 896-0719
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Albert LopezTIME COMPLETED:
01:30 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
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with facility staff Lisa, and explained the purpose of the visit. LPA was later met by designated staff Albert Lopez.

On 09/19/2024, LPA Valerio learned that Licensee/Administrator Edgar Enero sold the business. The facility is currently operating under a management company. Administrator Edgar informed LPA Valerio that an application was submitted for a Change of Ownership and the decision to do this was sudden. On 09/19/2024, LPA Valerio requested documentation related to 27-AS-20240917175201; however, Licensee Edgar did not provide the documents until 10/01/2024. Several attempts to obtain documentation were sent via e-mail with LPA Valerio and Licensing Program Manager (LPM) Stephen Richardson.

On 09/23/2024, LPA Valerio provided guidance to Licensee Edgar Enero regarding a Change of Ownership. LPA informed Licensee was to review PIN 21-05 and Health and Safety Code ยง1569.682 to ensure all necessary documentation is submitted timely to CCL.

On 10/01/2024, Licensee Edgar stated he was not sure if the Change of Ownership would occur, which is why he did not notify licensing. However, residents "were notified in advance that there was a possibility a couple months ago." LPM Richardson requested copies of the notice that was provided to each resident and/or their responsible party/person. As of 10/03/2024, the Regional Office has not received a copy of the notices. Designated Staff/Prospective New owners informed LPA they will send an email to LPA.

Per California Code of Regulations (CCR) - Title 22 - deficiencies are being cited on the attached LIC 809 - D. Appeal Rights were provided. An exit interview was held with Designated Staff Albert, and a copy of the report was provided. Designated Staff Albert stated he will communicate with Licensee Edgar.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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 2


Document Has Been Signed on 10/03/2024 01:20 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: SIGNATURE LIVING ON LAVELLI WAY
FACILITY NUMBER: 342700587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
87755(c)

1
2
3
4
5
6
7
87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated designated staff will inform Licensee Edgar of any additional documentation and ensure any documentation that is needed will be submitted to LPA Valerio timely.
8
9
10
11
12
13
14
The licensee did not ensure to provide copies of facility records to the Licensing Agency, which poses a potential health, safety, and personal rights 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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2