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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002840
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:54:22 PM


Document Has Been Signed on 06/22/2023 04:54 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ELIZABETH CARE HOMES IVFACILITY NUMBER:
345002840
ADMINISTRATOR:EKANEM, UWEM IMEFACILITY TYPE:
740
ADDRESS:7131 MATHIS COURTTELEPHONE:
(650) 248-1108
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection. LPA met with caregiver, Nneka Uchegbu, and additional caregivers, Maureen Ugiro and Otti Ekene. LPA observed (4) residents to be in the common area and (2) residents to be in their resident rooms at the start of the inspection. LPA spoke to Franca Offor, Co-Administrator, by phone, who later arrived at the facility at approximately 1:00 pm.

LPA was informed of the incident on 6/6/2023 when resident (R1) was not able to leave the facility with another individual/driver who was providing transportation to a scheduled appointment made the week prior. R1's physician's report (LIC602) notes R1 has a diagnosis of Parkinsons Disease and Schizophrenia and is able to follow directions and is not confused or disoriented. It is not indicated on the LIC602 if resident is able to leave the facility unattended as it was not completed.

R1's pre-appraisal dated 9/23/2020 indicates that resident is very alert, able to follow directions and enjoys and can carry a conversation. LPA and Ombudsman have recently talked to resident on several occasions and found this to be alert.

An inspection was conducted on 6/6/23 and the situation was discussed with the Co-Administrator, Franca, and staff at that time. All interviews indicated that due to resident not having left the facility before, without informing staff, staff wanted to ensure they knew where resident going and with whom. Conversation with the individual who had scheduled the appointment confirmed that the facility would not allow resident to leave and requested the driver provide information pertaining to where resident was going and with whom.

Based on information obtained, resident (R1) had a right to leave the facility and staff interfered.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being issued on the 809D page.
Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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 06/22/2023 04:54 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ELIZABETH CARE HOMES IV
FACILITY NUMBER: 345002840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2023
Section Cited
CCR
87468.1(a)(6)

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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: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
This requirement is not met as evicenced by:
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Licensee/Administrator agree to conduct staff training on Personal Rights regulations, including 87468/.1/.2 with staff and provide documentation of agenda/attendees to the Department by 7/6/2023.
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Based on interviews conducted, the facilty did not ensure that resident (R1) was able to leave the facility with a transportation provider for a scheduled appointment on 6/6/2023 at approximately 10:30 am, which posed a personal rights violation 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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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