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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004505
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:37:33 PM


Document Has Been Signed on 08/01/2023 03:37 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:ALL CARE, LLCFACILITY NUMBER:
347004505
ADMINISTRATOR:RAY GINFACILITY TYPE:
740
ADDRESS:5901 WITT WAYTELEPHONE:
(916) 714-5170
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 4DATE:
08/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Raymond Gin, AdministratorTIME COMPLETED:
03:45 PM
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On 8/1/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. Upon LPAs arrival, Caregiver Mei Chen was present at facility and contacted Administrator Raymond Gin who arrived a bit later. LPA met with Administrator Raymond Gin and explained the purpose of the visit.

The purpose of today’s visit was to follow up on a concern learned through an incident report. According to the incident report, on 7/19/23 resident R1 was having lunch with the other residents at the dinning table. Facility staff then notice that R1 was not interacting with the other residents and went over to check on R1. R1 did not respond to staff and had both her hands clinched. R1’s face began to change color and passed out. Paramedics arrive and took R1 to Kaiser. R1 was put on oxygen and passed way on 7/22/23. Based on staff interviews, staff stated that R1 did not show any signs of choking or hearth attack. Per Administrator, R1 has never choked before, has no history of choking and was able to eat on her own without issue. At this time, R1’ death certificate is not yet available for review.

Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. An exit interview was held and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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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