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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701182
Report Date: 04/13/2023
Date Signed: 04/13/2023 06:18:55 PM

Document Has Been Signed on 04/13/2023 06:18 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:ELLA ROSE CAREFACILITY NUMBER:
342701182
ADMINISTRATOR:HAMMETT, REBECCAFACILITY TYPE:
735
ADDRESS:9460 MAINLINE DRTELEPHONE:
(916) 316-6213
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 2DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Rebecca HammettTIME COMPLETED:
06:25 PM
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
On 4/13/23 at approximately 3:45pm Licensing Program Analysts (LPAs) Maja Jensen and Kimberly Viarella arrived unannounced to conduct a case management related to incident reports recently received for Resident 1 (R1). LPAs Jensen and Viarella met with Licensee Rebecca Hammett and explained the purpose of today's visit.

LPA Jensen reviewed partial resident files for 2 of 2 residents and interviewed 1 staff member and the Licensee. Due to time constraints, this case management will or may be continued at a later date.

During the course of the visit, LPA Jensen observed Resident 2 had a sustained a head injury that consisted of a scratch approximately an inch in length and there was no visible bruising. LPA Jensen asked Licensee if a report had been submitted. The Licensee advised that the fall was unwitnessed but the resident was taken to be evaluated by medical professionals and cleared therefore no report was made.

A deficiency is being cited from Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 2
Document Has Been Signed on 04/13/2023 06:18 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/13/2023 at 05:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELLA ROSE CARE
FACILITY NUMBER: 342701182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2023
Section Cited
CCR
80061(b)(1)

1
2
3
4
5
6
7
Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours....
(D) Any injury to any client which requires medical treatment.
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to email an attestation to maja.jensen@dss.ca.gov that she has read, understands and will comply with the regulation by the Plan of Correction due date.
8
9
10
11
12
13
14
Based on LPA Jensen's observation of R2's head injury and LPA Jensen interview with the Licensee the incident was not reported. This poses a potential risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2