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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:22:39 AM


Document Has Been Signed on 08/10/2023 11:22 AM - 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:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 53DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Morgan WhineryTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on several incidents. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. Whinery had to leave during this visit to make an appointment and said business office director Susie Sarria could sign this report in her absence.

LPA Moleski interviewed Whinery, and a staff member (S1) regarding two incident reports describing an act of aggression between residents (R1, R2), and regarding two incidents involving R3 and R4. R1 was out at the hospital at the time of this visit. LPA Moleski interviewed R4.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Sarria.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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