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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001680
Report Date: 04/07/2023
Date Signed: 04/07/2023 05:28:06 PM

Document Has Been Signed on 04/07/2023 05:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ELK GROVE SPRING HOMES INC.FACILITY NUMBER:
347001680
ADMINISTRATOR:TEJADA, CARMENCHITAFACILITY TYPE:
735
ADDRESS:8720 SECKEL CT.TELEPHONE:
(916) 686-5547
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
04/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Carmenchita TejadaTIME COMPLETED:
05:30 PM
NARRATIVE
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On 4/7/23 at approximately 4pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility to address some deficiencies that were observed during a Quality Assurance review conducted by the Regional Center on 3/27/23. LPA Jensen met with Carmenchita Tejada and explained the purpose of today's visit.

On 3/27/23 Alta Regional Center Service Coordinators observed a lock on the door knob leading from the entry hallway to the garage. The lock was oriented to the interior of the house. This doorway an identified fire exit and locking the door prevents access to a fire exit. This is a fire clearance violation and the lock was removed on 3/27/23.

The Regional Center Service Coordinator also observed on 3/27/23 locks on 2 bedroom closets which prevented residents from accessing their belongings. In addition the Regional Center Service Coordinator observed an alarm on a bedroom window and hygiene supplies stored in a locked laundry room which is a violation of personal rights.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6.

Civil Penalties are also being assessed.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 04/07/2023 05:28 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/07/2023 at 05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELK GROVE SPRING HOMES INC.
FACILITY NUMBER: 347001680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2023
Section Cited
CCR
80020(a)

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Fire Clearance
All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by:
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The Licensee has removed the lock from the fire exit effective 3/27/23 and no further Plan of Correction is required.
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Based on the Regional Center Service Coordinator's observation of a locked fire exit the fire clearance was not maintained as approved and this poses an immediate threat to the health, safety and personal rights of residents in care.
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Type B
04/07/2023
Section Cited
CCR85072(b)(6)

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Personal Rights
The licensee shall insure that each client is accorded the following personal rights:
To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by:

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The Licensee has removed the lock on teh closet doors and moved the hygiene products in to residents rooms effective 3/27/23 and no further plan of correction is required.
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The Regional Center Service Coordinator's observation of locked closet doors in resident bedrooms and locked hygiene supplies. This poses a potential risk to the health, safety and personal rights of 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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