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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:39:20 PM

Document Has Been Signed on 12/20/2024 12:39 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:ELITE ELDERLY CARE HOMEFACILITY NUMBER:
347005043
ADMINISTRATOR/
DIRECTOR:		CALAGUI, LANIFACILITY TYPE:
740
ADDRESS:8510 STONEFLOWER WAYTELEPHONE:
(916) 896-5185
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Joyce SmithTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) conduct an initial complaint visit. 27-AS-20241219093215 on 12/20/24 at 11:15a. LPA met with Joyce Smith, Caregiver and stated the purpose of the visit.

Joyce Smith contacted the Administrator regarding the purpose of the visit and that resident #1 (R1) file is not available for review. LPA spoke with Administrator regarding this deficiency.

LPA spoke with Administrator Lani Calagui who stated she is out of town and is not able to provide a copy of the file today.

Although the licensee understands the records are to be retained for a minimum of 3 years following termination of service to a resident, the records were not readily available for review during this visit and will not be ready during business hours today.

Based on admittance by the Licensee the records are not readily available for review or copying this will be cited today on this Case Management visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 809D during this visit.

Licensee was provided a copy of their rights (LIC9058) and their signature acknowledges receipt of these rights.

Exit interview held, a copy of report was provided.
Stephen RichardsonTELEPHONE: (916) 263-4746
Victoria BrownTELEPHONE: (209) 814-1955
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ELITE ELDERLY CARE HOME
FACILITY NUMBER: 347005043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Resident Records
The licensee shall ensure...record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
Deficient Practice Statement
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POC Due Date: 12/24/2024
Plan of Correction
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Licensee shall submit a copy of R1's complete file to the office by 12/24/24 as well as a written statement indicating the Title 22 regulations will be upheld at all times.
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.
Stephen RichardsonTELEPHONE: (916) 263-4746
Victoria BrownTELEPHONE: (209) 814-1955

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024

LIC809 (FAS) - (06/04)
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