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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004504
Report Date: 04/02/2021
Date Signed: 04/02/2021 09:53:40 AM

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:GORMLEY'S RETIREMENT HOMEFACILITY NUMBER:
347004504
ADMINISTRATOR:ELIZABETH M GORMLEYFACILITY TYPE:
740
ADDRESS:8774 KELSEY DRIVETELEPHONE:
(916) 684-9042
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
04/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth Gormley and Melissa MorenoTIME COMPLETED:
09:50 AM
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Licensing Program Analyst Ashley Boothe conducted an unannounced televisit with Licensee Elizabeth Gormley and Administrator Melissa Moreno at 9:30am via facetime. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 0. The facility is a 8 bedroom and 4 bathroom house. LPA observed the kitchen, living areas, bedrooms, bathrooms, and exterior.

LPA did not observe evidence of care and supervision at this time. LPA confirmed residents were relocated to other licensed care facilities.

LPA will close the facility case file as of todays date.

An exit interview was conducted with Licensee. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Licensee is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
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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