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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 08/28/2023
Date Signed: 08/28/2023 02:54:09 PM


Document Has Been Signed on 08/28/2023 02:54 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:MORGAN WHINERYFACILITY TYPE:
740
ADDRESS:6727 LAGUNA PARK DRTELEPHONE:
(916) 683-1881
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:108CENSUS: 46DATE:
08/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Morgan WhineryTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on a deficiency issued during this facility's annual inspection. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit.

LPA Moleski issued a citation on 7/20/23 for a resident (R3) diagnosed with dementia who had not received a new LIC 602 within a year as required. Whinery said attempts have been made to make an appointment for R3 to get a new LIC 602 but facility staff have not heard back from R3's hospital as of this date. LPA Moleski reviewed two fax transmittals dated 7/27/23 requesting an appointment for a new LIC 602 for R3. LPA Moleski reviewed a functional evaluation for R3 dated 7/31/23 which was faxed to R3's hospital along with another request for an appointment, according to Whinery. Whinery said the person responsible for faxing the functional evaluation did not keep the fax transmittal sheet, and no longer works at the facility. Whinery said she made two calls to the hospital, S1 made at least one call to the hospital, and R3's family member called as well. Whinery said she has made plans to have R3's LIC 602 renewed within the week by a concierge physician, due to the lack of response from R3's hospital.

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: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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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