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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700722
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:35:27 PM


Document Has Been Signed on 02/07/2023 01:35 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:WELLQUEST OF ELK GROVEFACILITY NUMBER:
342700722
ADMINISTRATOR:MAURER, JENNIFERFACILITY TYPE:
740
ADDRESS:8871 E STOCKTON BLVDTELEPHONE:
(916) 689-1000
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:170CENSUS: 74DATE:
02/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jennifer MaurerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with Administrator Jennifer, explained the purpose of the visit.

On 01/27/2023, the Regional Office received an incident report from WellQuest of Elk Grove. The incident report stated that a staff member, Staff 1 (S1), accidentally let a resident, Resident 1(R1), out of the memory care unity. S1 believed that R1 was a family member visiting a resident in the memory care unit. According to R1's records, R1 is diagnosed with dementia and is unable to leave the facility unassisted. The facility discovered resident was missing 50 minutes after S1 let R1 out. Video footage was reviewed and revealed R1 left the facility. Family and law enforcement was contacted. R1 was returned to the facility with the help of the fire department. Resident was assessed by EMTs and put on alert charting. According to the administrator, staff were immediately given an in-service training. LPA obtained copies of in-service training and list of staff attendance.

LPA followed up on another incident report dated 02/01/2023. The incident report involved a resident that was observed to have a change of condition and was sent to the hospital. Resident has returned and is doing well.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, a deficiency is be cited today on LIC 809-D. Appeal rights were provided. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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 02/07/2023 01:35 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: WELLQUEST OF ELK GROVE
FACILITY NUMBER: 342700722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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87705 Care of Persons with Dementia (c) Licensees...shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff... shall receive...training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement was not met as evidenced by:
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Licensee stated they have implemented staff in-service trainings and will continue to implement signs on doors to remind staff to check before letting anyone out. Licensee to send copies on in-services and signage by POC due date.
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Based on records review and interviews, the licensee did not ensure staff (S1) was properly trained to ensure that 1 out 24 memory care residents were kept safe from wandering out of the facility, which poses 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
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