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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 12/30/2024
Date Signed: 12/30/2024 03:08:54 PM

Document Has Been Signed on 12/30/2024 03:08 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:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR/
DIRECTOR:		JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 180TOTAL ENROLLED CHILDREN: 0CENSUS: 140DATE:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jennell ReveraTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit.

LPA Moleski reviewed death reports for two residents (R1-R2) dated 12/27/24 and 11/14/24, respectively. LPA Moleski reviewed R1's and R2's resident records. LPA Moleski interviewed Revera and a staff member (S1) regarding these reports.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Revera.
Stephen RichardsonTELEPHONE: (916) 263-4746
Vincent MoleskiTELEPHONE: (559) 365-5294
DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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