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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:04:23 PM

Document Has Been Signed on 11/16/2022 02:04 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:BEATRICE SENIOR CAREFACILITY NUMBER:
342701159
ADMINISTRATOR:MITITI, BIANCAFACILITY TYPE:
740
ADDRESS:8901 MELODIC CTTELEPHONE:
(916) 270-3961
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bianca MititiTIME COMPLETED:
12:00 PM
NARRATIVE
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LPA Johnson conducted an unannounced case management visit. LPA met with Administrator and explained the purpose of today’s visit. The Department found an issue and concern while opening the complaint control number 27-AS-20221024150556. The concern is being addressed in this case management visit today.

During a review of facility records and resident medical records, LPA learned that resident #1 (R1) is seeing a home health nurse. On 10/04/22 the resident’s order information from Dr.Kaur confirmed that R1 has a "non-healing open wound of the right heel. The identified medically necessary was identified as Skilled Nursing.

On 11/2/2022 R1's daughter informed LPA that R1 pressure injury was on the heel and Unstageable. LPA requested that document be provided to the facility that confirm the stage of the wound. During the visit today the Administrator confirmed that R1 has an unstageable wound on the right heel.

There is no discharge papers that identified the stage of the wound. However, the resident needs home health for the unstageable wound on her heel.

The licensee/administrator did not request for an exception for the prohibited health condition as required.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/16/2022 02:04 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/16/2022 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87616(a)(b)(1,2)

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Exception for Health Conditions: The licensee may submit a written exception if she/he agrees the resident has a prohibited health condition but believes that the intent of the law can be met through alternative means. Written request shall include... documentation of resident’s health condition…licensee’s plan for ensuring the resident’s health related needs can be met by the facility.

This requirement is not met as evidenced by:
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Licensee agrees to submit a request for an exception to retain (R1) who has prohibited health condition. Licensee shall review the regulation on prohibited health condition and submit a statement of understanding of this regulation.
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Based on interview and review of medical record on 10/04/2022 and medical discharge
paperwork, the licensee/staff failed to seek an exception as required to retained R1 with a
prohibited health condition. This posed a potential health and safety risk to resident’s in
care.
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By close of business on 11/17/2022

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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