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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701182
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:50:07 PM

Document Has Been Signed on 08/09/2023 12:50 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:
08/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rebecca HammettTIME COMPLETED:
11:30 AM
NARRATIVE
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On 8/9/23 at approximately 10:15am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at the facility unannounced to conduct a case management visit for deficiencies. LPAs Jensen and Fain met with Administrator Rebecca Hammett and explained the purpose of today's visit.

The Department received notification from the Regional Center that Resident 1 (R1) was taken to the hospital and discharged same day on 6/24/23. The resident was not accepted back in to the facility until 6/26/23. Based on an incident report received by the Regional Center (UCI # 5034043), on 6/24/23 R1 was taken to the hospital at approximately 7pm for evaluation. At 8:48pm, R1 was cleared to return home however the Administrator stated she was not willing to accept R1 back in to the facility due to concerns for the safety of care staff and other clients residing in the home. On 6/27/23 a service coordinator/facility liaison conducted an unannounced visit to the facility and verified with staff 1 (S1) that R1 was accepted back in to the home on 6/26/23. The Regional Center determined that according to R1's Individual Program Plan dated 3/6/23, R1's schedule of supports include a provision requiring staff to follow R1 to the Emergency Room and advocate on R1's behalf. It also requires staff to remain with R1 until R1 is either medically discharged or admitted to the hospital. On 6/24/23 staff did not accompany R1 to the Emergency Room to advocate on their behalf or remain with R1 until discharged.

As a result of this incident deficiencies are being cited for violations of the California Code of Regulations (CCR), Title 22, Division 6. In addition, a civil penalty is being assessed for repeat violations relating to reporting requirements.

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: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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Document Has Been Signed on 08/09/2023 12:50 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/09/2023 at 09:07 AM
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: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2023
Section Cited
CCR
85064(j)(4)

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Administrator Qualifications and Duties
The administrator shall perform the following duties:...
Provision of, or insurance of the provision of, services to the clients, required by applicable law and regulation, including those services identified in the client's individual needs and services plans. This requirement was not as evidenced by:

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The Licensee has conducted an inservice training with staff on the specifics of R1's IPP as of 7/14/23 and the Licensee has written a formal policy/procedure requiring staff to accompany residents to the Emergency Room. No further plan of correction is required.
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Based on the Regional Center FAR, the Licensee did not meet the requirements of R1's IPP when R1 was sent to the hospital and R1 was not readmitted to the facility until 6/26/23 despite being discharged from hospital on 6/24/23. This poses an immediate risk to the health, safety and personal rights of 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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