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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:57:22 PM


Document Has Been Signed on 04/27/2023 12:57 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITYFACILITY NUMBER:
347005512
ADMINISTRATOR:JAMES HALLFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 47DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Morgan WhineryTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Ruth Wallace arrived unannounced for a case management visit regarding an incident report received by licensing. LPAs Moleski and Wallace met with the administrator and explained the purpose of visit.

The incident report stated that R1 had not been given medication in accordance with doctor's orders. LPAs Moleski and Wallace reviewed R1's MARs for March and April, two doctor's orders for R1, and centrally stored medications for R1. LPAs Moleski and Wallace observed doctor's orders received by the facility on 3/13/23 ordering R1 to take 5 milligrams of dementia medication once per day for two weeks, then increase to one tablet twice a day. MARs for R1 showed that R1 started the dementia medication on 3/14/23 with a dose of one tablet twice a day between 3/14/23 and 3/27/23.

This facility is being cited per 22 CCR Section 87465(4). Appeal rights and a copy of this report was left with the administrator. An exit interview was conducted with the administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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Document Has Been Signed on 04/27/2023 12:57 PM - 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY
FACILITY NUMBER: 347005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited

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Incidental Medical and Dental Care - 87465(4): "The licensee shall assist residents with self-administered medications as needed."
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Licensee agrees to conduct staff training for medical technicians on transferring doctor's orders to MARs properly. POC due date is 5/11/23. Licensee agrees to submit via email to LPA Moleski proof of training.
vincent.moleski@dss.ca.gov
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This requirement was not met based on LPA review of R1's medication records.

This violation poses a potential risk to health and safety of residents 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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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