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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700949
Report Date: 02/27/2025
Date Signed: 02/27/2025 05:26:31 PM

Document Has Been Signed on 02/27/2025 05:26 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/
DIRECTOR:		HUFF, MARCUSFACILITY TYPE:
735
ADDRESS:6261 FIELDALE DRIVETELEPHONE:
(323) 459-8068
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Michael OlivaTIME VISIT/
INSPECTION COMPLETED:
05:35 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 three resident files (R1-R3) and three staff files (S1-S3). R2 did not have a current IPP on file. R2's most recent IPP on file was dated from 2021. R3 also didn't have a current IPP on file, and their most recent IPP was dated from 2022.

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 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

While touring the facility, LPA Moleski observed several containers of laundry detergent left unlocked in the laundry room. The door to the laundry room cannot lock.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and 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 cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and one resident (R1).

This facility is hereby cited per 22 CCR Sections 85070(a)(3) and 80087(g). An exit interview was held with Oliva. Appeal rights and a copy of this report was left with Oliva.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 3
Document Has Been Signed on 02/27/2025 05:26 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/27/2025 at 05:04 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: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, detergent was left in unlocked storage areas readily accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee removed the detergents and moved them to locked storage space during this visit. This POC will be cleared.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/27/2025 05:26 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/27/2025 at 05:04 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: 02/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85070(a)(3)
Client Records
(a) In addition to Section 80070, each client record must contain the following information: (3) Needs and Services Plan and any modifications thereto, as specified in Sections 80068.2, 80068.3, 85068.2 and 85068.3.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, current IPPs were not maintained in two resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee acquired copies of the residents' IPPs from ACRC and forwarded them to LPA Moleski during this visit. This POC will be cleared.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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