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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701040
Report Date: 12/26/2023
Date Signed: 12/26/2023 01:54:08 PM


Document Has Been Signed on 12/26/2023 01:54 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:BRUCEVILLE POINTFACILITY NUMBER:
342701040
ADMINISTRATOR:HOSTETTER, ERICFACILITY TYPE:
740
ADDRESS:9730 BACKER RANCH ROADTELEPHONE:
(916) 226-5300
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:200CENSUS: 143DATE:
12/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Misty VelozTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit to follow up on an incident report submitted to the Department.  LPA met with designated staff person Misty Veloz, and explained the purpose of the visit.

On 12/12/23, The Department received an Unusual Incident/Injury Report submitted by Resident Services Director Misty Veloz. On 12/12/23, Resident 1 (R1) was found laying on the floor of the bathroom after R1's spouse altered staff via pull cord. R1 was sent to the hospital and received a diagnosis of a fractured hip.

LPA requested additional information regarding R1 (LIC 602, Needs and Service Plan, Death Report, and any supportive documents) be sent to LPA Valerio.

According to an interview with staff, R1 had previous health conditions and was on hospice prior to passing away.

No deficiencies are being cited on today's visit.

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: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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