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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701218
Report Date: 01/08/2024
Date Signed: 01/08/2024 05:06:59 PM


Document Has Been Signed on 01/08/2024 05:06 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:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rosa Elma QuiambaoTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 1/8/24 at 2:45pm. Administrator Certificate expires 5/11/2024.

LPA met with Rosa Elma Quiambao and stated the purpose of todays visit.

The facility is licensed for a capacity of 6 Non-Ambulatory residents of which 3 may receive hospice care services.

LPA received a copy of the documentation submitted to Community Care Licensing for the name change from Jones at Saddle Way to Royal Grove Care Home.

LPA observed the Infection Control Plan during this visit.

Due to time constraints LPA will return on a later date to conclude the annual visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies 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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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