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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 02/27/2024
Date Signed: 02/27/2024 02:31:39 PM


Document Has Been Signed on 02/27/2024 02:31 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:CALAGUI, LANIFACILITY TYPE:
740
ADDRESS:8510 STONEFLOWER WAYTELEPHONE:
(916) 896-5185
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lani CalaguiTIME COMPLETED:
02:30 PM
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A Non-Compliance Follow-up Meeting was held today via Microsoft Teams 2/27/24 at 1:30pm to discuss the compliance to regulations. The attendees of the meeting were: Regional Manager (RM) Stephenie Doub,
Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Victoria Brown and Licensee/Administrator Lani Calagui. RM began the meeting by stating the purpose of the meeting and introductions began.
Subject areas discussed:
-Prior Probation during 2016
-Citations in May 23 and August 23
-(TSP) Technical Support Program response
-Catheter use by residents
-Staffing/Supervision
-Diagnosis of Dementia/wandering
-License fees/Annual is coming due
-Present questions/concerns to Community Care Licensing (CCL)
CCL expectations:
-Facility shall continue ongoing self-audits
-Facility shall submit prior to acceptance waivers and exception requests; review regulations and requirements
-Facility shall ensure exit alarms are audible for residents with wandering tendencies and staffing is awake
-Facility shall respond to TSP engagement letter and/or contacts
-Facility shall contact CCL/LPA/LPM/On-Duty Worker with any questions or concerns
To ensure the facility is successful in remaining in compliance, CCL will submit a TSP referral.
At this time, quarterly visits will cease.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited.
An exit interview was held. Administrator agreed to a copy of this report being provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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