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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 02/10/2023
Date Signed: 02/27/2023 11:45:33 AM


Document Has Been Signed on 02/27/2023 11:45 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BEATRICE SENIOR CAREFACILITY NUMBER:
342701159
ADMINISTRATOR:CLARK, TIMOTHYFACILITY TYPE:
740
ADDRESS:8901 MELODIC CTTELEPHONE:
(916) 270-3961
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
02/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chudean Roper, CaregiverTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced on 02/10/23 at approximately 9:00 am and was greeted by Caregiver Chudean Roper. LPA entered the facility and was led into a clean unobstructed area where one resident was sitting on the couch and four residents were in the dining room eating breakfast. Caregiver Ken Morris was present as well.

R1 was sitting at the head of the table eating. A catheter bag could be seen beside her ankle. LPA confirmed with caregiver Roper that this was the new resident and that she had a catheter. No exception request has been approved as of this date however nurses had trained staff in R1’s care over a period of three days. Citation issued.

LPA spoke to Administrator, who was out of the country, by phone. Administrator continued to assert that no exception was needed and that she did not know how to write the exception request. LPA reminded her that she could refer to the regulations. LPA had also provided a redacted exception letter as a basic guide. Before leaving, an exception letter was provided that will require review.

LPA inquired as to who was the designated authority for the facility. Neither staff member was aware and were unfamiliar with the Designation of Facility Responsibility form when shown. Administrator stated she had designated R2 as the responsible person but the form could not be found and the administrator did not know where it could be.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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 02/27/2023 11:45 AM - 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

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87616(b) Exceptions for Health Conditions The licensee may submit a written exception request if ... the resident has a ...restrictive health condition. This requirement was not met as evidenced by:
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Licensee will submit an exception request for resident with catheter. Exception was received during inspection of facility.
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Based on observation, interviews and record review, the new resident has a catheter and no exception request was received before her arrival.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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