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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004234
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:46:05 PM

Document Has Been Signed on 10/17/2024 12:46 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:REACH ADULT DEVELOPMENT SITE #3FACILITY NUMBER:
347004234
ADMINISTRATOR/
DIRECTOR:		SUH, SEANFACILITY TYPE:
775
ADDRESS:2204 KAUSEN DR STE 120TELEPHONE:
(916) 539-0588
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 45CENSUS: 35DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Shobhna MudaliarTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with program director Shobhna Mudaliar and explained the purpose of the visit.

LPAs Moleski and Williams reviewed six client files (C1-C5, C9) and six staff files (S1-S6). Two clients (C4 and C9) did not have signed admission agreements on file. LPA Moleski asked Mudaliar for C4's initial admission agreement. Mudaliar produced an admission agreement dated today's date, 10/17/2024. Mudaliar was not able to produce an original admission agreement for C9 and said she would be drafting a new admission agreement for them.

LPAs Moleski and Williams toured the facility with Mudaliar and inspected common areas, the kitchen, and classrooms. Furniture and furnishings were sufficient to meet the needs of clients. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a locked container for the storage of medication. LPA Moleski observed locked areas for the storage of cleaning solutions and knives.

LPA Williams interviewed three staff members (S1, S4, and S6) and three clients (C6-C8).

This facility is being cited per 22 CCR Section 82068(e). An exit interview was held with Mudaliar. Appeal rights and a copy of this report were left with Mudaliar.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10/17/2024 12:46 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/17/2024 at 12:31 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: REACH ADULT DEVELOPMENT SITE #3
FACILITY NUMBER: 347004234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(e)
Admission Agreements
(e) The licensee shall retain in the client's file the original of the initial admission agreement and all subsequent modifications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not, retain original admission agreements for two clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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LPA Moleski was provided a new admission agreement for C4. Licensee agrees to provide LPA Moleski a new admission agreement for C9 by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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