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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:27:57 AM


Document Has Been Signed on 02/03/2023 10:27 AM - It Cannot Be Edited

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:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 121DATE:
02/03/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
10:15 AM
NARRATIVE
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On 2/3/2023 at 10:00 am, Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an office meeting with facility administrator Jennell Revera regarding reporting requirements.

LPA Ivey Canady explained the reason for the meeting. LPA discussed facility incident reporting requirements based on Title 22 Regulations.


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

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058 3/22) and their signature on hard copy via email acknowledges receipt of these rights.

An exit interview was conducted, and a copy of this report was emailed to administrator Jenele Revera.

See 809D for continuation...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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 2


Document Has Been Signed on 02/03/2023 10:27 AM - 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
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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/03/2023
Section Cited
CCR
87211(a)(2)

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87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...This was not met as evidenced by:

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Licensee stated there will be a training conducted on reporting requirements for outbreaks and infections and will submit a copy of the sign in sheet for the training to LPA no later than 2/4/2023 5pm.
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Based on the incident report dated 1/19/2023 received from the licensee there was a Covid 19 outbreak that began on 1/15/2023. According to Title 22 Regulations, the outbreak was not reported within regulatory timelines. This poses an immediate health and safety risk to persons 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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