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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 06/26/2023
Date Signed: 06/26/2023 02:29:35 PM


Document Has Been Signed on 06/26/2023 02:29 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: 42DATE:
06/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Morgan WhineryTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit following up on an incident report. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit.

On 6/6/23, a resident (R1) called 911 during mealtime. A medical technician overheard R1 calling 911. According to the incident report, R1 said that R1 "was not feeling well."

LPA Moleski interviewed S1 regarding the incident report. S1 said that R1 had shown and expressed no previous signs or symptoms. LPA Moleski reviewed R1's LIC 602 and daily notes for the month of June 2023. R1's daily notes indicate that R1 was treated for neck pain and discharged with no new orders the same day. S1 said that staff reminded R1 that R1 can ask staff to get help if needed.

LPA Moleski interviewed R1. R1 did not express any concerns regarding facility staff members or staffing levels.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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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