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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701218
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:35:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/15/2024 12:35 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: 4DATE:
03/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosa Elma QuiambaoTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the annual visit on 3/15/24 at 9:00am. LPA met with Rosa Elma Quiambao and stated the purpose of the visit.

Administrator Certificate expires 5/11/2024.

The facility is licensed for a capacity of 6 Non-Ambulatory residents of which 3 may receive hospice care services. LPA conducted a review of 2 resident records and 2 staff records. LPA observed the Infection Control Plan during this visit.

There is 0 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 116.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

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: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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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