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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701052
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:52:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2024 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240403102443
FACILITY NAME:ELIZABETH CARE HOMEFACILITY NUMBER:
392701052
ADMINISTRATOR:FAJARDO, GERALDINEFACILITY TYPE:
735
ADDRESS:3674 POPOLO CIRCLETELEPHONE:
(510) 289-3848
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
07/26/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Geraldine Fajardo TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility does not provide activities to residents in care.
Facility does not provide adequate food to meet the residents’ needs.
Facility staff do not follow the facility menu.
Facility staff do not update residents' records.
Facility does not follow residents’ care plan.
INVESTIGATION FINDINGS:
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On 07-26-2024 at 9:50 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to open a complaint investigation with the above allegations. LPA Martinez met with Geraldine Fajardo and explained the purpose of today's visit.

During today's visit, LPA Martinez reviewed dietician reports, recreation therapy consulting resource binder, conducted a food supply inspection, and reviewed facility menus. LPA Martinez reviewed the dietician report, and it was learned there were no concerns with the meals being served. In addition, the dietician has visited the facility this year to conduct assessments and audit facility menus. LPA Martinez also inspected the food supply, and observed the facility had the food Ingredients to server what was on the July meal menu. LPA Martinez observed an adequate food supply.

Continued...
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240403102443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ELIZABETH CARE HOME
FACILITY NUMBER: 392701052
VISIT DATE: 07/26/2024
NARRATIVE
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The facility has a resident council meeting monthly. The facility has an activity agenda, which residents sign at the time of an activity. LPA Martinez observed all clients signatures on activity agendas. Also, the facility is visited by a recreation therapy consultant monthly. LPA Martinez reviewed client 1 (C1) monthly nursing summaries. Monthly summaries are from March 2024 to June 2024. July's monthly summary will be conducted on August 1, 2024. The summaries are maintained with the current information. Staff 1 reported C1 had no recent health changes that would require their assessment to be updated.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2