342700722-9-4-2024-27-AS-AVIA-D8SVPT-20240904163716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700722
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:37:30 PM

Document Has Been Signed on 09/04/2024 04:37 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 GROVE		FACILITY NUMBER:	342700722
ADMINISTRATOR:	CUEVAS, ELANA		FACILITY TYPE:	740
ADDRESS:	8871 E STOCKTON BLVD		TELEPHONE:	(916) 689-1000
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	170	CENSUS: 105	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Elena Cuevas		TIME COMPLETED:	02:30 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	On 9/4/24, at 10:20am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their required annual inspectiont. LPA met with Elena Cuevas, current Executive Director (ED), and explained the purpose of the visit. The facility currently has an approval to retain/accept 25 hospice residents and fire cleared to retain/accept 20 bedridden residents in the first floor. LPA and ED inspected the physical plan of the facility to ensure compliance of Title 22 regulation. Facility is a 3-story building consisting of Memory Care (MC), located in the 1st floor, and Assisted Living (AL) in the 1st, 2nd and 3rd floor. LPA observed all floors of the facility, the activity room, dining room, cinema room, elevator, and random resident apartments/units. Facility has a 170-resident capacity for both assisted living and memory care residents. Facility also has Independent Living area (IL). Facility has a pool area and was observed to be fenced, locked and inaccessible to some residents. Per interview with ED, some residents are provided supervision when they use the pool. LPA observed a shaded area in the yard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. LPA observed medication rooms in the AL and MC side and medications were observed to be properly stored, locked and inaccessible to residents in care. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 3 of 3 resident apartments/units were observed to be clean, sanitary and free of obstruction. Bathrooms were observed to be clean, maintained and in good repair. Memory care has delayed egress doors. Kitchen and dining area were observed to be clean and sanitary. During this visit, kitchen staff were observed to be preparing lunch. Sharps, cleaning supplies and toxins were observed to be locked and inaccessible to residents. Kitchen refrigerators and freezers were observed to be cleaned and in good repair and were maintained at regulatory temperatures. Hot water temperature in 1 randomly selected bathroom (in a resident apartment/units) were measured at between 115 degrees F. Room temperature in the hallways were observed between 70 and 75 degrees F. One elevator was observed to be in good working condition. Facility has 4 stairwells and 2 were inspected and were observed to have evacuation chairs. Con't to LIC809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 5

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
	VISIT DATE: 09/04/2024

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
26
27
28
29
30
31
32

LPA conducted record review of 6 resident files and 6 staff files and found to be in compliance at this time. LPA also reviewed facility emergency drill and facility conducts evacuation drills at least quarterly. During this visit, LPA discovered 2 residents in care in the AL area became bedridden status and were living in units not fire cleared for bedridden residents.

LPA obtained a copy of their current resident roster, staff roster, current Liability Insurance Certificate and updated LIC308.

The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties.

An exit interview was conducted with Elena Cuevas, ED, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/04/2024 04:37 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: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. 2 residents became bedridden status and were living in units that are not fire cleared for bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Licensee will provide LPA with a written plan of correction indicating the steps facility will take to be in compliance by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5