Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 07/18/2019
Date Signed: 07/19/2019 09:07:35 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: 131DATE:
07/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Amanda Smith and Cynthia SilveriaTIME COMPLETED:
04:30 PM
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Unannounced case management visit made out to this facility on 07/18/2019 and was met by the Director of Resident Services, Cynthia Silveria, and the facility designated Administrator, Amanda Smith, who were both briefly interviewed.
Current census was 131 residents.
The purpose of this visit was to follow up on an unusual incident report, LIC 624, that was submitted into CCL in regards to resident R1 that took place in the early part of July 2019.
It was learned that a third party caregiver inappropriately attempted to transfer R1 from a sitting position and caused bruising to R1 as a result. It was learned that facility staff intervened when they observed the inappropriate assist and were able to properly assist with R1 in getting him/her transferred and transported to the hospital for further evaluation.
It was learned that this particular third party caregiver was no longer present nor employed in this facility. It was learned that this facility has contracted with a different third party company to provide services unto residents who wish to do so.

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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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