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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701120
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:31:09 PM

Document Has Been Signed on 04/13/2023 03:31 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:FREDERICKSON HOME IIFACILITY NUMBER:
342701120
ADMINISTRATOR:FREDERICKSON, VALERIEFACILITY TYPE:
735
ADDRESS:5320 MATINA DR.TELEPHONE:
(916) 686-7358
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Valerie Frederickson, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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On 4/13/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. Upon LPAs arrival, Direct Care Staff Mavictoria Agra was present and contacted Administrator Valerie Frederickson who arrived a bit later. LPA met with Valerie Frederickson and explained the purpose of the visit. There are currently 5 residents who reside at this facility.

The purpose of the visit today is in response to substantial inadequacies identified by Alta California Regional Center during an annual Title 17 Monitoring Review on 3/29/23. It was learned that the facility was placed on sanction on 4/6/23 due to the following deficiencies:
- Failure to provide consumer services as specified in the consumer’s IPP.
- Failure of a Service Level 4 facility to utilize the instructional methods and techniques which are specified in the facility’s program design.

As a result, the following deficiencies were cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

Exit interview was conducted, a copy of this report, 809-D, and appeal rights were provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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Document Has Been Signed on 04/13/2023 03:31 PM - It Cannot Be Edited


Created By: Tung Truong On 04/13/2023 at 02:57 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FREDERICKSON HOME II
FACILITY NUMBER: 342701120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
85064(j)(4)

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Administrator Qualifications and Duties. (j) The administrator shall perform the following duties… (4) Provision of, or insurance of the provision of, services to the clients, required by applicable law and regulation, including those services identified in the client's individual needs and services plans.
This requirement is not met as evidenced by:
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Licensee will develop a plan of care and supervision to include how Administrator will develop procedures on providing services to clients based on their care needs. Licensee/Administrator shall submit a written plan of correction to LPA by 4/14/2023.
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Based on records review, the licensee did not provide services to clients as specified in client’s IPP. This poses an immediate health and safety risk to clients 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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