347005464-8-10-2021-27-AS-THUD-C5RQYB-20210810123451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 08/10/2021
Date Signed: 08/10/2021 12:35:16 PM

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 GROVE		FACILITY NUMBER:	347005464
ADMINISTRATOR:	AMANDA SMITH		FACILITY TYPE:	740
ADDRESS:	6915 ELK GROVE BLVD.		TELEPHONE:	(916) 714-2404
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	180	CENSUS: 122	DATE:	08/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adminsitrator-Jennell Revera		TIME COMPLETED:	01:00 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	On 8-10-21 at 10:00 am Licensing Program Analyst (LPA) Tirzah Hubbard arrived unannounced to conduct a Required Annual 1 Year inspection. LPA met with Jennell Revera Administrator and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 180 clients. Census: 122 Hospice: 3 Home Health: 5 Covid-19 positive: 2 Residents; Staff: 3- ( Residents have been placed on quarantine isolated in room since 8-5-21) (1 Staff has been quarantined since 7-31-21 and 2 staff 8-2-21 at home). LPA observed positive residents are placed on the second floor of the facility. Fully Vaccinated residents:115 Partially vaccinated: 0 Fully Vaccinated staff: 110 partially vaccinated staff: 3 LPA interacted with a random number of residents during this visit. Designated Administrator stated, "Staff testing for Covid-19: twice a week; Resident testing: twice a week". The physical plant was toured inside and outside to ensure the safety of the residents. LPA toured the kitchen area, courtyard, front yard, bedrooms on first and second floor of the facility. All rooms contained: Bed, dresser, refrigerator, microwave, desk, chair, railing in bathroom, and table set. LPA observed the physical plant of the facility in good condition. LPA observed the flooring of the facility in good condition and hallway flooring in good condition. LPA observed the facility conducts fire drills every month. LPA observed medication stored and locked away inaccessible to persons in care located on second floor. LPA observed medication logged properly. TA visit will be scheduled during visit on 8-10-21 .

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

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
	VISIT DATE: 08/10/2021

NARRATIVE

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LPA observed the kitchen area in compliance. LPA observed lunch being served to all residents in the facility.The refrigerator contained food items properly labeled and packaged. The freezer contained packaged and labeled meat. LPA observed food supplies of staple nonperishable food stored for emergency. There were perishable foods for a minimum of two days that shall be maintained

LPA observed the courtyard in compliance and accessible to all residents of the facility.

The temperature inside the facility was measured at 75 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.

The hot water was measured at 110*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed the smoke detectors in residents room. LPA observed smoke detector in dining and kitchen area.

Documents requested during visit: LIC 308, LIC 602, LIC500, received on 8-10-21 during Annual visit.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC809 (FAS) - (06/04)

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