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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 04/18/2023
Date Signed: 04/18/2023 01:37:33 PM


Document Has Been Signed on 04/18/2023 01:37 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: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: 4DATE:
04/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Beatrice ClarkTIME COMPLETED:
01:30 PM
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On 4-18-23 at Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a receipt of a death report. LPA met with Beatrice Clark and explained the purpose of the visit. LPA reviewed death report received on 3-30-23 and updated on 4-4-23 which revealed resident1 (R1) passed away on 3-25-23 due to lewy body dementia. LPA reviewed death certificate for R1 which revealed lewy body dementia as a cause of death. Based on interview conducted with Administrator, R1 was experiencing shortness of breath on 3-25-23 at approximately 12:30pm and 911 was called in under approximately 1 minute. R1 was not on hospice at the time. Based on interview, it was determined that a hospice referral was considered when admitted to facility 2-4-23 but ultimately was not made as R1's condition began to improve. Administrator called hospital to inquire about condition and was told at 1:48pm that R1 passed away.

As a result of today’s case management, no citation is issued. An exit interview was conducted with Beatrice Clark and a copy of this report was provided to Beatrice.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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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