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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005512
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:38:30 PM


Document Has Been Signed on 07/28/2022 12:38 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
CCLD Regional Office, 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: 52DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:James Hall - Executive DirectorTIME COMPLETED:
12:45 PM
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 Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection visit. LPA met with Executive Director (ED) and explained to him the purpose of today's visit. Administrator Certificate Expires 11/19/2023.

There are currently 52 residents who reside at this facility. This facility has a hospice wavier for 15 and currently has 5 residents on Hospice and 6 on Home Health. This facility has 6 different cottages. 3 serving as Assisted Living and 3 serving as Memory Care. LPA toured all 6 cottages with ED. LPA observed with ED each cottage with a dining area and a medication room.

Facility roster indicated Birch cottage has 13 residents. Facility roster indicated Aspen cottage has 14 residents. Cedar is currently vacant for remodeling. Dogwood is vacant. Facility roster indicated Elm cottage has 11 residents. Facility roster indicated Fir has 13 residents. LPA observed toxins and medications locked in all cottages with residents. LPA conducted a sample medication audit in several cottages. LPA spot checked several resident rooms in each cottage occupied. All rooms were found to be odor free. LPA observed sufficient 2+day perishable and 7+day non-perishable food and observed locked sharps in the kitchen and locked toxins in the laundry area. LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expire 2/15/2023. Facility is conducting quarterly fire drills and the last one was conducted 06/27/2022. The hot water measured 108.2*F which is within the required range of 105-120*F.

A review of (5) facility resident records was conducted and all have required documents for Community Care Licensing (CCL). A review of (7) facility personnel records was conducted. All staff are fingerprint cleared and associated to the facility. All staff have current First Aid certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.
There were no deficiencies cited from California Code of regulations, Title 22 found during today’s inspection.
Exit interview conducted with Executive Director and a copy of report left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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