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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:31:54 PM


Document Has Been Signed on 12/07/2023 04:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
12/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Beatrice ClarkTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) arrived unannounced on 12/7/23 at 3:45p to conduct a health and safety check of the residents residing in the home. LPA met with Beatrice Clark, Administrator and stated the purpose of the visit.

LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 1 residents receiving hospice care services at this time.

LPA observed residents preparing for dinner during this visit.

LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit.

LPA observed caregiver(s) performing other duties during this visit.

LPA did not observe any health and safety hazards during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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