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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:40:48 PM


Document Has Been Signed on 06/09/2023 03:40 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: 5DATE:
06/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jerome TecsonTIME COMPLETED:
04:00 PM
NARRATIVE
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On 6/9/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to address deficiencies learned from a complaint investigation for complaint control number: 27-AS-20230217163200. LPA met with Administrator Designee Jerome Tecson and stated the purpose of today’s visit.

On 6/7/2023, the Department completed the complaint investigation for the complaint mentioned above. Based on interviews and records review, it was determined that the facility has failed to follow licensing regulations to request for an exception to retain R1 with a prohibited health conditions and to notify licensing of R1's pressure injuries.

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: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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 06/09/2023 03:40 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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2023
Section Cited
CCR
87615(a)(1)

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87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to... (1) Stage 3 and 4 pressure injuries.
This is requirement is not met as evidenced by:
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Facility will not admit or retain residents with a prohibited health condition. Licensee shall ensure all staff are trained, for no less than (1) hour in duration, on the topic of Prohibited Health Conditions, and submit proof of training into CCL by the due date.
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Based on interviews and records review, the licensee retained R1 who has a stage 3 pressure injury without an exception approval from the Department. This poses an immediate health, safety, and resident rights risk for residents in care.
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This documentation should include the topic of the training, attendees, and the name of the qualified trainer.
Type B
06/16/2023
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency...within seven days...
This is requirement is not met as evidenced by:
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Licensee shall review Reporting Requirements Section 87211 regulation and conduct an in-services training on reporting requirement for all staff.
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Based on interview and record review, the licensee did not ensure to report to CCL regarding R1 change in condition for any new pressure ulcer developed. This poses a potential health, safety for residents in care.
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Licensee agrees to email LPA Truong in-service training materials; and review regulation statement; and training sign in sheet by POC Date.
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: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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