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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701302
Report Date: 08/12/2024
Date Signed: 08/12/2024 11:25:00 AM


Document Has Been Signed on 08/12/2024 11:25 AM - 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:A CARING HOMEFACILITY NUMBER:
342701302
ADMINISTRATOR:TOLENTINO, ELAINEFACILITY TYPE:
740
ADDRESS:6813 ELVORA WAYTELEPHONE:
(916) 685-3093
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
08/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Elaine TolentinoTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit - health and safety check. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Administrator Elaine Tolentino.

LPA Valerio received notification from an outside agency regarding COVID positive residents and staff inside the facility. LPA Valerio reviewed the Regional Office (RO) electronic facility files and did not observe any submitted incident reports. LPA attempted to contact the facility on 08/06/24, but did not receive a response. On 08/07/24, LPA Valerio was able to reach Administrator Elaine via cellphone. Initially, Administrator Elaine stated she only had one resident that was COVID positive. After further discussion, it was learned that two residents were COVID positive. Both residents were in a shared room. According to Administrator Elaine, no staff tested positive. LPA inquired about the facility's Infection Control Procedures. Due to the facility's full capacity, Administrator Elaine stated there was no available room to be utilized as an isolation room. Administrator Elaine admitted that an incident report was not sent for the COVID cases. LPA requested they be sent to the RO. The RO received two incident reports on 08/08/2024.

According to the Unusual Incident Reports (UIR) received, Resident 1 (R1) returned from the hospital on 07/21/24. Staff observed R1 displayed cough symptoms. R1 tested positive for COVID on 07/25/2024. R1 was in a shared bedroom with Resident 2 (R2). R2 was not removed from the room, and R1 was not isolated per the facility's infection control procedures. On 07/28/2024, R2 was observed to have symptoms of a cough and tested positive for COVID.

Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 809 - D. Appeal rights provided. Failure to correct deficiencies may result in the issuance of civil penalties. An exit interview held, and a copy of the report was provided to Administrator Elaine.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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 08/12/2024 11:25 AM - 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: A CARING HOME
FACILITY NUMBER: 342701302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2024
Section Cited
CCR
87470(a)

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87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows... This requirement was not met as evidenced by:
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Licensee will submit an in-service training for Administrator and all staff regarding current CCLD and LPH guidelines for COVID positive cases. Licensee to submit proof of training along with a detailed plan of how the facility will address COVID cases in the future.
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Based on records review and interviews, The licensee did not ensure infection control practices were followed by staff to minimize the spread of COVID, which poses an immediate health, safety, and personal rights risk to residents in care.
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 Licensee to send by POC due date.
Type A
08/13/2024
Section Cited
CCR87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable... This requirement was not met as evidenced by:
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Licensee will submit an updated Infection Control Plan that addresses individuals in a shared room and the facility's plan to ensure all residents safety in the future. Licensee to send by POC due date.
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Based on records review and interviews, the licensee did not ensure to remove R2 from the shared bedroom once R1 was learned to be positive for COVID, which poses an immediate health, safety, and personal rights 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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/12/2024 11:25 AM - 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: A CARING HOME
FACILITY NUMBER: 342701302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2024
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency...: (2)Occurrences, such as epidemic outbreaks....which threaten the welfare, safety or health of residents,, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer...
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Licensee to send an acknowledgement of understanding letter regarding 87211 by POC due date of 08/13/2024. Licensee to conduct in-service training on Reporting Requirements and send proof of training by 08/26/2024.
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This requirement was not met as evidenced by:
Based on records review and interviews, the licensee did not ensure COVID cases were reported via phone or via a written report, which poses a potential health, safety, and personal rights risk to residents in care.
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Type B
09/12/2024
Section Cited
CCR87405(d)

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87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.... This requirement was not met as evidenced by:
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Licensee will have administrator submit an acknowledgement of understanding of Infection Control Requirements, Personal Rights of Residents in All Facilities, and Reporting Requirements.
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Based on records review and interviews, the licensee did not ensure Administrator Elaine provide care and supervision appropriate to the residents and did not show ability to conform to the applicable laws, rules and regulations when two residents tested positive for COVID, which poses a potential health, safety, and personal rights 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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3