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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 11/17/2020
Date Signed: 11/17/2020 11:05:32 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:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:AMANDA SMITHFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 113DATE:
11/17/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:TIME COMPLETED:
10:49 AM
NARRATIVE
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Licensing Program Analyst (LPA) Suong Teh contacted the facility via telephone to commence a Tele-visit on 11/17/2020 due to COVID-19 and pre-cautionary measures. LPA spoke to the facility Executive Director Amanda Smith and discussed the purpose of the call and the elements of this type of visit.

On 11/17/2020 @ 0801 hours, an attempt unannounced virtual visit was made with the facility Executive Director Amanda Smith. @0807 hours, 0809 hours and 0815 hours LPM Stephen Richardson called the facility and learned from the front desk staff that there was no one in charge to assist licensing with the TA virtual visit.

The preponderance of evidence standard has been met. Therefore, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Amanda Smith via telephone and a copy of this report was provided via email.

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARLTON PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/18/2020
Section Cited

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Administration and management of residential care facilities; substituted qualifications; employee scheduling:
At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day.
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The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:
(2) Familiarity with the facility’s planned emergency procedures.: Based on today unannounced virtual visit @0815 hours, 11/17/2020, no staff was able to conduct a virtual visit. This poses a potential health risk to the residents in care.

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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2020
LIC809 (FAS) - (06/04)
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