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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:56:23 PM


Document Has Been Signed on 07/25/2022 03:56 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
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: 119DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennell Revera - AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required Annual 1 Year Inspection Visit. LPA met with 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: 119
Hospice: 6 Home Health: 8

The physical plant was toured inside and outside to ensure the safety of the residents. LPA and Administrator 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 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.
LPA observed the kitchen area in compliance. LPA observed breakfast being served to some 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. LPA interacted with a random number of residents during this visit.

Continued on 809-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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


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: 07/25/2022
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Continued from 809 - Page 2

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 113.4*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 LPA observed a pull alarm system, fire extinguisher(s) checked 2/2/2022, 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.

LPA reviewed (4) staff files. All staff is fingerprint cleared and associated to the facility. All staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed (8) resident files and all documents required by Community Care Licensing were current in files.

LPA requested during visit: LIC 308, LIC 500, LIC 610E, received on 7/25/22 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 to Administrator
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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