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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004078
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:55:50 PM

Document Has Been Signed on 01/18/2023 12:55 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:BHI-RUSH CREEK HOMEFACILITY NUMBER:
347004078
ADMINISTRATOR:THELMA ENRIQUEZFACILITY TYPE:
735
ADDRESS:9467 RUSH CREEK COURTTELEPHONE:
(916) 685-3776
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Thelma CasugayTIME COMPLETED:
11:00 AM
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On 01/18/2023, Licensing Program Analyst Renee Campbell arrived to the facility at approximately, 9:00 am. LPA was met by staff Ricardo Pumaloy. LPA explained the purpose of the visit for a case management.

Approximately two months ago on 11/14/22, a resident stepped out of a shower and began to turn blue. There were four staff, and 6 residents present in the facility at the time. Staff called 911. Resident was treated and with medication and discharged with care notes. LPA reviewed client file, 602, staff schedule and confirmed IR hardcopies. Resident had no emergency contacts outside of the doctor. Alta and the doctor were notified, and an appointment made for the resident for further assessment. Yearly resident examinations are up to date. Resident has returned to facility with weekly Home Health Nurse visits and is recovering satisfactorily. No deficiencies found at this time.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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