<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 08/17/2023
Date Signed: 08/17/2023 03:15:49 PM


Document Has Been Signed on 08/17/2023 03:15 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 121DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jennell ReveraTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit.

The incident report described an alleged theft in a resident's (R1) apartment on 8/2/23. LPA Moleski reviewed R1's file and interviewed Revera. R1 allegedly had a ring and two five dollar bills stolen. Revera said an agreement was made to compensate R1 for the items, and two staff members (S1-S2) were terminated.

Revera said another resident (R2) had recently made a report of missing money. LPA Moleski reviewed R2's file. LPA Moleski reviewed the facility's theft and loss policy.

LPA Moleski interviewed R1 and R2.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Revera.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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 1