342700587-11-7-2023-27-AS-TTRG-CXD24E-20231107160349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700587
Report Date: 10/25/2023
Date Signed: 11/07/2023 04:03:53 PM

Document Has Been Signed on 11/07/2023 04:03 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 WAY		FACILITY NUMBER:	342700587
ADMINISTRATOR:	ENERO, EDGAR		FACILITY TYPE:	740
ADDRESS:	10125 LAVELLI WAY		TELEPHONE:	(916) 896-0719
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	10/25/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Edgar Enero		TIME COMPLETED:	04:30 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	A Non-Compliance Conference was held via Microsoft Teams on October 25, 2022, at 3:30 PM. The Department explained the purpose of this office meeting to the Licensee/Administrator of Signature Living at Lavelli Way. The following were in attendance: Sacramento South Regional Manager Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Tung Truong, Licensing Program Analyst (LPA) Christina Valerio, Sacramento North Regional Manager Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang and facility Licensee/Administrator(s) Edgar Enero. The purpose of today's conference is to discuss non-compliance issues. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. Since the facility was licensed, three (3) Type A deficiencies have been cited. The facility was cited for the following issues: Incidental Medical and Dental Care, Prohibited Health Conditions, and Reporting Requirements. *Issues discussed during the meeting were:* - The amount of complaint's filed against this facility since licensure. - Incidental Medical and Dental Care - Prohibited Health Conditions - Providing Timely Medical Care Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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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
	VISIT DATE: 10/25/2023

NARRATIVE

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- Reporting Requirements
- Resident Records
- Care and Supervision issues
- Increase monitoring from Licensing
- Recommended Licensee of Residential Technical Support Program (TSP)

The facility has stated they will do the following to achieve continued and substantial compliance: Please provide the following documents to LPA Tung Truong by 11/10/23:
- Submit all required documents to change facility administrator
- Provide an updated LIC 500 for all facilities to LPA
- All staff including the administrator shall receive training on how to recognize change(s) in condition and what to do
- All staff and administrator shall receive refresher training on Prohibited Health Condition to be completed.
- All staff and administrator shall receive In-service training on Reporting Requirements
- All staff and administrator shall receive training on Pre-placement appraisals/reappraisal assessment
- All staff and administrator shall receive training on skin integrity, skin checks and how to observe potential injuries.

The regional office advised the licensee that increased monitoring to the facility in the next nine months will be initiated to ensure compliance. The Licensee was offered Technical Support through the Technical Support Program but the licensee declined at this time.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are cited during this visit. An exit interview was conducted with Edgar Enero and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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