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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700949
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:35:20 PM

Document Has Been Signed on 01/09/2024 04:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FIELDALE FACILITYFACILITY NUMBER:
342700949
ADMINISTRATOR:HUFF, MARCUSFACILITY TYPE:
735
ADDRESS:6261 FIELDALE DRIVETELEPHONE:
(323) 459-8068
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michael OlivaTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Michael Oliva and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and four staff files (S1-S4). R2's LIC 602, dated 3/29/22, indicates that R2 is nonambulatory. The LIC 602 indicates that R2 is considered nonambulatory based on R2's mental condition. Oliva said R2 did not have a more recent LIC 602. This facility is approved to accept only ambulatory residents, per the facility license.

LPA Moleski toured the facility with Oliva and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked storage areas for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and one resident (R4).

This facility is being cited per 22 CCR Section 80010(b). An exit interview was conducted and a copy of this report was left with Oliva.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 01/09/2024 04:35 PM - It Cannot Be Edited


Created By: Vincent Moleski On 01/09/2024 at 04:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FIELDALE FACILITY
FACILITY NUMBER: 342700949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee retained a nonambulatory resident since 3/29/22, while the facility license indicates the facility is approved for only ambulatory residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Licensee agrees to draft a written plan of action regarding the violation of ambulatory/capacity status per the facility license, and to email LPA Moleski a copy of the statement by 1/10/24.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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