<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 03/25/2024
Date Signed: 03/25/2024 10:50:27 AM


Document Has Been Signed on 03/25/2024 10:50 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 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:
03/25/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Beatrice ClarkTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/25/24 at 8:30am on a subsequent visit. This visit is to conduct a health and safety check of the residents residing in the home. LPA met with Beatrice Clark and stated the purpose of the visit. The Administrator certificate for Beatrice Clark expires 10/30/25.

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 2 residents receiving hospice care services at this time.

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.

During LPA visit the temperature inside the facility measured to be at 68*F which is within the required range of 68-85*F. The water temperature measured at 116.5*F which is within the required range of 105-120*F.

LPA observed caregiver(s) performing other duties during this visit. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA did not observe any hazards for residents at this time.

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: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1