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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701218
Report Date: 05/20/2024
Date Signed: 05/20/2024 06:26:38 PM


Document Has Been Signed on 05/20/2024 06:26 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:
05/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:52 PM
MET WITH:Rosa Elma QuiambaoTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst(s) Victoria Brown and Arvin Villanueva arrived unannounced to conduct an initial 10 day visit on 5/20/24 at 4pm on a subsequent visit. LPAs met with Rosa Elma Quiambao and stated the purpose of the visit. LPAs observed the following during this visit:
2 caregivers during the visit one of which was not finger print cleared an both are not associated to the facility.
LPAs observed medications on the counter and dining table in a 7-day pill box accessible to resident's.

LPAs observed the fire extinguisher on the wall that has an expiration date of 8/11/22.

LPAs did not observe a register of records for staff or residents during this visit.

Based on 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: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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 3


Document Has Been Signed on 05/20/2024 06:26 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: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee shall write a letter stating the medications are locked and made inaccessible to residents.
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This requirement is not met as evidenced by: Based on Administrator confirmed that the medications were accessibile and should not be.
This violation poses an immediate health, and safety risk to residents in care.

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Type A
05/21/2024
Section Cited
CCR87465(h)(5)

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Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee shall write a letter stating the medications are not transferred between containers in a 7 day pill box.
Type A
05/21/2024
Section Cited
CCR
87203

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by: Based on LPAs observed the card on the fire extinguisher has not been updated since 8/11/22.
This violation poses an immediate health, and safety risk to residents in care.
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Licensee shall submit a letter stating the fire extinguisher has been replaced or the fire department has reviewed it for safety and working condition.
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: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/20/2024 06:26 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: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2024
Section Cited
CCR
87355(e)(1-3)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or Request a transfer of a criminal record clearance as specified in Section 87355(c) or Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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Licensee shall write a letter stating the 2 caregivers will be associated to the facility and the other to be finger print cleared.
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This requirement is not met as evidenced by: Based on LPAs observed on LIS and Guardian System that the 2 caregivers are not associated to the facility but 1 was never finger printed. This violation poses an immediate health, and safety risk to residents in care.
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Type A
05/21/2024
Section Cited
CCR87508(a)(1-3)

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Register of Residents
The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: The resident's name and ambulatory status as specified in Sections 87506(b)(1) and (b)(10). Information on the resident's attending physician as specified in Section 87506(b)(7).Information on the resident's responsible person as specified in Section 87506(b)(6).
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Licensee shall write a letter stating that a register of residents and staff shall be made available to CCL when requested
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This requirement is not met as evidenced by: Based on LPAs did not observe a readily available roster of residents or staff. 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: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3