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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001680
Report Date: 04/16/2024
Date Signed: 04/16/2024 11:55:13 AM

Document Has Been Signed on 04/16/2024 11:55 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:ELK GROVE SPRING HOMES INC.FACILITY NUMBER:
347001680
ADMINISTRATOR/
DIRECTOR:		TEJADA, CARMENCHITAFACILITY TYPE:
735
ADDRESS:8720 SECKEL CT.TELEPHONE:
(916) 686-5547
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
04/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Carmenchita TejadaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a case management visit on 4/16/24 at 8:45am. LPA met with Carmenchita Tejada and stated the purpose of the visit. LPA interviewed Carmenchita Tejada and Staff #1 (S1) regarding a records error on medication that was found during an Alta Regional Center visit. S1 indicated that during the administration of medication, the visit occurred and 1 box of the MARs was missing an initial indicating the resident received the medication. Both stated the medication was not missed as it would be indicated when resident #1 (R1) would have a behavior.
LPA also observed training certificates (CEUs) taken by both Carmenchita Tejada and Clifford Tejada for the year of 2022-2023 which will be submitted to Regional Center as proof that classes were completed during that year.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, 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 Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

Exit Interview held and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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Document Has Been Signed on 04/16/2024 11:55 AM - It Cannot Be Edited


Created By: Victoria Brown On 04/16/2024 at 11:08 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
80070(a)

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Client Records
The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Licensee shall submit a sample of the revised record keeping to be used for medication administration which shall be faxed by POC due date.
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This requirement was not met as evidenced by: Based on interviews and admittance of Administrator and S1 that the initials indicating the medication has been administered was missing on the MARs for R1.
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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 Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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