<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001680
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:35:21 PM

Document Has Been Signed on 07/10/2024 04:35 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: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: 3DATE:
07/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Clifford Tejada TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to obtain information regarding an Incident Report submitted on 5/12/2024 on 7/10/24 at 3:30p.

The incident report indicated that resident #1 (R1) upon arrival to the facility from an outing in the community dashed out the van door and ran towards the shopping center. Staff was able to follow to a certain point, however, due to traffic laws could not keep up with the resident. Staff reported R1 missing to law enforcement and stated the direction and was told they already had someone fitting the description and to come pick resident up from a clothing store. Resident was located and picked up from the police in front of the store, however, the resident was having a behavior in which personal shoes were discarded. Staff could not locate the shoes that R1 threw away. R1 had more shoes at the facility and more were bought after which R1 discarded 2 more pairs of shoes while at the facility.

Based on staff losing sight of the resident, a deficiency shall be cited during this visit.
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: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 2
Document Has Been Signed on 07/10/2024 04:35 PM - It Cannot Be Edited


Created By: Victoria Brown On 07/10/2024 at 04:09 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
, 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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
80078(a)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision

The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Licensee shall write a letter stating they will reitrate the calendar for outtings and shopping and ensure observation of residents at all times which shall be faxed by POC due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on interviews and admittance of Administrator that R1 was not observed the entire time away from facility.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2