347005512-7-28-2021-27-AS-THUD-C5CS44-20210728133206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 07/28/2021
Date Signed: 07/28/2021 01:32:27 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:	ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY		FACILITY NUMBER:	347005512
ADMINISTRATOR:	JERICA HOWARD		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108; 108	CENSUS: 47	DATE:	07/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Susie Sarria Business Officer Manager		TIME COMPLETED:	01:40 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 7-28-21 at 9:30am Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced Annual visit. LPAs met with Mary Ann, Health and Wellness Coordinator, and Susie Sarrie, Business Officer Manager, to discuss the purpose of the visit. Census: 48 Staff Census: 10 Mitigation plan has been received during visit on 7-28-21. LPAs observed 2 hospice, 3 bedridden with bedridden clearance for Brook Dale Elk grove location. LPAs have requested updated Bedridden and Hospice clearance documents by 7-30-21 for Pegasus Elkgrove. LPAs have received hospice and bedridden documents for Brookdale location.. LPAs observed all Caregivers with Finger print clearance. LPAs toured physical plant of facility. The facility contained 6 cottages total with two memory care. LPAs observed the memory Cottage in compliance. LPAs observed medication logged into MARS up to date in memory care cottage. LPAs met with S1 to discuss medication log in and schedule. LPAs observed medication not logged properly Cottage 1, 2, and 3. MARS contained incorrect log in dates and medication administration. LPAs met with S2 Medication Aide for cottage 1, 2 and 3 to discuss the medication guidelines for logging into MARS. LPAs observed cob webs and bugs located around the doors of each cottage of the facility. LPAs observed each cottage containing dirt and stains located on each carpet of the cottages needing cleaning and replacement. LPAs observed each window of the facility needing cleaning. Thermostat: 70 degrees

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
	VISIT DATE: 07/28/2021

NARRATIVE

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LPAs requested documents to be submitted for file review:

LIC 500
LIC308
LIC 400
LIC 610

The hot water was measured at 116 *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.

LPAs Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPAs observed the smoke detector located in the kitchen in disrepair and detached from ceiling.

LPAs observed food supplies of staple nonperishable foods. There were perishable foods for a minimum of two days that shall be maintained on the premises at all times. The kitchen staff left food unattended and un covered to take a phone call on 7-28-21. The Kitchen manager covered the food and spoke to the kitchen staff for leaving food uncovered. The sharp objects that are : Knives, forks, and spoons were locked away.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed and cited on LIC809 D. Exit interview held, copy of report given on 8-15-21 return visit. Appeal rights printed.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed cob webs and bugs located in the corner of each cottage which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2021
	Plan of Correction
1 2 3 4	Administrator has notified maintenance to clear all bugs and cobwebs. LPAs observed taking each cob web down.

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs oberserved flooring of each cottage containing dirt and stains with needs of replacement, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/10/2021
	Plan of Correction
1 2 3 4	Administrator has agreed to place a work order in for carpet cleaning for all 6 cottages by POC date.

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review the licensee did not comply with the section cited above. LPAs observed night shift caregiver did not log medication administered at 6:30am for dates 7-27-21 and 7-28-21 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Adminstrator agrees to change MARS log in documents reflect medication adminsitered on 7-27-21 and 7-28-21 at 6:30am.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

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