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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 05/18/2023
Date Signed: 05/18/2023 01:57:51 PM


Document Has Been Signed on 05/18/2023 01:57 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:
05/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Beatrice Clark - AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Case Management Visit - Incident. LPA explained purpose of visit to administrator.

LPA conducted tour throughout facility with administrator. LPA discussed incident regarding resident (R1) and a fractured left ankle which occurred on May 3, 2023. R1 was taken to Emergency Services (ER) Kaiser South in the morning and returned on same day at approximately 5:00 PM.

Home Health services will be conducting physical therapy for approximately three times a week. A new needs and services plan will be put in place with responsible party before the end of May 2023. Plan will determine if daily living activities of R1 need more staff assistance.

No deficiencies were observed or cited from the California Code of Regulations, Title 22.

Exit interview conducted with administrator and a copy of report was left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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