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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701218
Report Date: 12/28/2023
Date Signed: 12/28/2023 05:07:45 PM


Document Has Been Signed on 12/28/2023 05:07 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:ROYAL GROVE CARE HOMEFACILITY NUMBER:
342701218
ADMINISTRATOR:ROSA ELMA QUIAMBAOFACILITY TYPE:
740
ADDRESS:9559 LAZY SADDLE WAYTELEPHONE:
(916) 829-4117
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 2DATE:
12/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jovita Aduca, CaregiverTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent closure visit on 12/28/2023 at 3:30p. LPA met with Jovita Aduca, Caregiver and stated the purpose of the visit.

During the closure visit LPA requested to review 2 resident files which were incomplete.

In addition, the caregiver attempted to call the Licensee/Administrator regarding the visit and at this time 4:36pm the caregiver(s) have not received a call back.

Based on file reviews and observation these deficiencies will be cited during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

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

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

An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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 12/28/2023 05:07 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: ROYAL GROVE CARE HOME
FACILITY NUMBER: 342701218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Licensee shall submit a plan on when the resident records will be completed to be submitted by fax to CCL by POC due date.
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This requirement is not met as evidenced by: Based on file reviews and LPA observation of documents are incomplete and or missing from residents file. This violation poses an immediate health, and safety risk to residents in care.
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Type A
12/29/2023
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties
... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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Licensee shall submit and LIC500 to include the hours Administrator is present in the facility and contact numbers for all staff to be submitted by fax to CCL by POC due date.
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This requirement is not met as evidenced by: Based on LPA observation that S1 attempted to contact Administrator and a call back was not received during this visit. This violation 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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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