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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:05:52 PM


Document Has Been Signed on 02/21/2023 03:05 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
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) 896-0719
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 3DATE:
02/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jerome TecsonTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced Case Management visit to address deficiencies observed during a complaint 10 Day visit on 2/21/23. LPA met with Administrator Designee Jerome Tecson and explained the purpose of today’s visit.

During the complaint 10 Day visit on 2/21/23, LPA Truong requested to review resident's #1 (R1) file. LPA was advised by administrator Egar Enero that R1’s file is currently with R1’s daughter. Administrator later stated that R1’s daughter came to the facility to pick up R1’s belongings and left R1’s file at the facility. However, facility staff were unable to locate the file in the facility.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were left at the facility. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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 02/21/2023 03:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SIGNATURE LIVING ON LAVELLI WAY
FACILITY NUMBER: 342700587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
Section Cited

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
This requirement is not met as evidence by:
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Licensee/Administrator shall provide a signed and dated statement of understanding of CCR 87506(a) and ensure that all residents records remain on file that is available for inspection by CCL at all times. POC will submit to licensing by 2/22/23.
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Based on LPAs visit on 2/21/23, the licensee did not have resident #1 (R1)'s records in the facility upon request for review, which posed an immediate health and safety risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
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