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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700722
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:10:42 PM


Document Has Been Signed on 12/21/2023 01:10 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:WELLQUEST OF ELK GROVEFACILITY NUMBER:
342700722
ADMINISTRATOR:SIMON, CASEYFACILITY TYPE:
740
ADDRESS:8871 E STOCKTON BLVDTELEPHONE:
(916) 689-1000
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:170CENSUS: 85DATE:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Elena Cuevas, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/21/23, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit on recent incident reports regarding falls. LPA met with the current Administrator, Elena Cuevas, and the facility Regional Health and Wellness Director, Rochelle Factor, and explained the purpose of the visit.

During this visit, LPA reviewed fall incident reports and resident files for Resident_1 (R1), R2, R3, R4, R5, R6, R7 and R8. Falls were reported between the dates of 9/29/23 and 11/24/23. LPA also interviewed Elena Cuevas and Rochelle Factor. Of the 8 resident falls reviewed, 7 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that the facility has now implemented a fall prevention protocol which include frequent checks on residents in care, especially those on fall risks. Per interview, residents who had falls are put on high alert and encourage residents to enroll the EmpowerMe Wellness program which include physical therapy, occupational therapy and speech therapy. Additionally, residents who are fall risk will have their medications evaluated by their primary care physician to determine if any of their current medications can contribute to falls. Additionally, residents carry a fall pendant. Administrator and Health and Wellness Director is planning to conduct in-service training next week to address falls and incident reporting.

A discovery during a resident file review that a death report was submitted to the Department on 11/13/23. However, review of the death report indicates that the date of death of the resident was on 10/30/23. Per interview confirms the date on the death report and the reporting date are accurate.



Per California Code of Regulations, Title 22, deficiencies were observed or cited during today's case management inspection. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared.

An exit interview was conducted with Elena Cuevas and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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 12/21/2023 01:10 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: WELLQUEST OF ELK GROVE
FACILITY NUMBER: 342700722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
87211(a)(1)(A)

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(a) (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events...(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
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Licensee to submit a declaration of understanding regarding the reporting requirementS specified in the CCR 87211 by the POC due date.
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This requirement is not met as evidenced by:
Based on record review and interview, a death report was submitted to the Department past the seven days requirement, which poses/posed a potential health, safety or personal rights risk to persons 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: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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