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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 05/05/2025
Date Signed: 05/05/2025 01:09:57 PM

Document Has Been Signed on 05/05/2025 01:09 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BEATRICE SENIOR CAREFACILITY NUMBER:
342701159
ADMINISTRATOR/
DIRECTOR:		CLARK, TIMOTHYFACILITY TYPE:
740
ADDRESS:8901 MELODIC CTTELEPHONE:
(916) 270-3961
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
05/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Beatrice ClarkTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit.

Upon entry, LPA Moleski observed two caregivers working in the facility (S1-S2). LPA Moleski reviewed Guardian records and observed that neither S1 nor S2 were associated to this facility. Clark said S1 had been working at this facility for just under one month. S2 said they had been working at the facility for one month. LPA Moleski asked to review this facility's centrally stored medication records. Clark said she did not have any current centrally stored medication records.

LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2). Resident files were missing several required forms. R1 had a blank PRN authorization on file, and had no needs and services plan. R2's appraisal was dated 8/1/23, which is more than one year old. R2 also had a blank PRN authorization form on file. R3 had a needs and services plan on file, but it was not complete and was missing significant pertinent information regarding R3's needs. R4's admission agreement was unsigned, and they did not have an appraisal, personal rights form, consent form, PRN authorization form, or needs and services plan on file. R5 did not have a needs and services plan or PRN authorization form on file. R6 did not have a file present at the facility. Clark emailed LPA Moleski a medical discharge form to LPA Moleski for R6, but could not produce further documentation regarding R6, such as a medical assessment.

LPA Moleski asked for S1 and S2's file. Clark said that S2 did not have a file at this facility. S1's file was missing an LIC 501. [continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159
VISIT DATE: 05/05/2025
NARRATIVE
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LPA Moleski toured the facility with Clark and inspected common areas, the kitchen, bedrooms, bathrooms and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 135 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies and carbon monoxide/smoke detectors. While touring, LPA Moleski observed medications in the refrigerator which were not kept in locked storage. LPA Moleski also observed cleaning solutions, including some containing bleach, which were left unlocked in a cabinet under the kitchen sink and under a sink in a resident bathroom. LPA Moleski observed fire extinguishers which had not been serviced within the last year, as required. The fire extinguishers were last serviced on April 15, 2024.

This facility is hereby cited per 22 CCR Sections 87202(a), 87303(e)(2), 87309(a), 87355(e)(3), 87465(h)(2), 87412(a), 87506(b), 87465(h)(6). Due to a violation of criminal record clearance requirements, a civil penalty of $100 per day worked by both S1 and S2, with a maximum of five days each, is hereby assessed. An immediate civil penalty in the amount of $500 is also assessed due to a violation of fire clearance requirements. Civil penalties assessed during this visit total $1500. An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/05/2025 01:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/05/2025 at 12:29 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, fire extinguishers were not annually serviced, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Licensee agrees to schedule maintenance service for their fire extinguishers by POC due date. Licensee shall inform LPA Moleski of the scheduled date of maintenance by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperatures measured above 120, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Licensee adjusted the water heater during this visit. Licensee agrees to retest and to provide LPA Moleski with a photograph of the updated reading by POC due date.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/05/2025 01:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/05/2025 at 12:29 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions were not kept in locked storage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Licensee removed the offending substances during this visit. This POC will be cleared.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, two staff members were not associated to this facility's roster which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Licensee sent in transfer requests during this visit. LPA Moleski will clear this POC after they have been transferred.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 01:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/05/2025 at 12:29 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were left in unlocked storage in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
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Licensee removed the medications during this visit. This POC will be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/05/2025 01:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/05/2025 at 12:29 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, S1's staff file was incomplete and S2's staff file was not present, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
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2
3
4
Licensee agrees to provide scans of both S1 and S2's complete staff files by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, resident files were incomplete, and one was missing altogether, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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Licensee agrees to provide complete scans of all resident files by POC due date.
vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/05/2025 01:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/05/2025 at 12:29 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
"(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

(A) The name of the resident for whom prescribed.

(B) The name of the prescribing physician.

(C) The drug name, strength and quantity.

(D) The date filled.

(E) The prescription number and the name of the issuing pharmacy.

(F) Instructions, if any, regarding control and custody of the medication."

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, centrally stored medication records were not kept, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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2
3
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Licensee agrees to write a statement acknowledging the requirements of this section and affirming that centrally stored medication records will be kept in the future by POC due date.
vincent.moleski@dss.ca.gov
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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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