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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 06/17/2024
Date Signed: 06/17/2024 03:31:21 PM


Document Has Been Signed on 06/17/2024 03:31 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: 5DATE:
06/17/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Beatrice ClarkTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/17/24 at 8:45am to conduct a Case Management - Health Checks visit. LPA met with Joan Young, Caregiver then 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 1 residents receiving hospice care services at this time. During LPA visit the temperature inside the facility measured to be at 73*F which is within the required range of 68-85*F. LPA observed caregiver(s) performing other duties during this visit. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishables. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
LPA Observation during visit:
*License fees not paid that was due on 5/3/24. Pin number was given as an option to pay online to become current.
*Flies in the facility.
*Did not have non-perishables fruits
*The water temperature measured at 143.7*F which is within the required range of 105-120*F.
*LPA observed the centrally stored medications area to be unlocked and accessible to residents, on table in room 1 with 2 residents present in bed
*Facility is using 7 day pill boxes
*Medications are stored with chemicals in garage
*Resident #1 (R1) was requesting to be dressed and staff #1 (S1) stated you are not going anywhere and that R1 always ask for the pants.
*S2 does not have a file available for review during the visit
*Administrator/S2 does not have fingerprint clearance or association documentation
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87156(a)

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Licensing Fees
An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
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Licensee/Administrator shall pay license fees by POC due date and fax confirmation to the CCL office.
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This requirement has not been met by: Based on the file review conducted by LPA VBrown the license fees are not current.
This poses an immediate health and safety risk to residents in care.
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Type A
06/18/2024
Section Cited
CCR87555(b)(27

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General Food Service Requirements
All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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Licensee/Administrator shall submit a plan to rid the home of flies by POC due date and fax confirmation to the CCL office.
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This requirement has not been met by: Based on the observation of LPA VBrown the Licensee/Administrator did not keep facility free of flies in the kitchen and common bathroom of the facility.
This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Licensee/Administrator shall turn down water heater by POC due date and fax confirmation to the CCL office. Also keep a water log for 1 week to be submitted by fax.
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This requirement has not been met by: Based on water temperature measured by LPA VBrown the licensee/Administrator did not ensure water was within required range. This poses an immediate health and safety risk to residents in care.
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Type A
06/18/2024
Section Cited
CCR87555(b)(26)

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General Food Service Requirements
Supplies of nonperishable foods for a minimum of one week...shall be maintained on the premises.
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Licensee/Administrator shall purchase nonperishable fruits and receipt to be faxed by POC due date.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a variety of fruits were present on premisis. This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities
To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Licensee/Administrator shall submit a plan on when an inservice to provide personal rights training to all staff will occur by POC due date and fax confirmation to the CCL office. Completion of in-service with signature shall be faxed to the office.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/S1 did not ensure R1 received dignity by assisting with clothing.
This poses an immediate health and safety risk to residents in care.
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Type A
06/18/2024
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee/Administrator shall submit confirmation that medications are inaccessible to residents by POC due date and fax confirmation to the CCL office.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure medications were locked and inaccessible.
This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87465

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Incidental Medical and Dental Care
Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee/Administrator shall submit a letter stating medication are not stored in 7 day pill boxes by POC due date.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications were not in its orignal container until medication pass was to occur.
This poses an immediate health and safety risk to residents in care.
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Type A
06/18/2024
Section Cited
CCR87309(b)

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Storage Space
Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.
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Licensee/Administrator shall submit a letter stating medication are not stored with chemicals in the garage by POC due date.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications are disposed of properly.
This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87412(a-h)

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Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...
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Licensee/Administrator shall ensure a file is created and maintained for all staff. A letter of confirmation shall be submitted by fax to the office by POC due date.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a file was created for S2. This poses an immediate health and safety risk to residents in care.
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Type A
06/18/2024
Section Cited
CCR87411(g)(1-3)

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Personnel Requirements - General
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
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Licensee/Administrator shall submit a plan to ensure S2 is cleared and associated to the facility by POC due date and fax confirmation to the CCL office.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure S2 was fingerprint cleared and associated to the facility. This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 06/17/2024 03:31 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87305(b)

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Alterations to Existing Building or New Facilities
The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
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Licensee/Administrator shall submit a plan to seek confirmation from the Fire Dept on the approval of the shed being used as a living space or ensure it is used for its proper use by POC due date and fax confirmation to the CCL office.
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This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure staff was not sleeping in the shed in the backyard. This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159
VISIT DATE: 06/17/2024
NARRATIVE
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Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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