342701336-4-22-2025-27-AS-KVIA-DFYVWS-20250422164824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701336
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:48:38 PM

Document Has Been Signed on 04/22/2025 04:48 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:	ELIXIR CARE HOME		FACILITY NUMBER:	342701336
ADMINISTRATOR/ DIRECTOR:	DULAY, MARIA G		FACILITY TYPE:	740
ADDRESS:	1440 HOOD ROAD		TELEPHONE:	(916) 565-1468
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 6		CENSUS: 2	DATE:	04/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Maria Dulay		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual Inspection visit was made by Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes to this facility on 04/22/25. LPAs identified themselves upon arrival, stated the purpose of the visit, and met with the Licensee/Administrator, Maria "Gloria" Dulay. A brief interview followed. LPA presented Licensee/Administrator with a list of documents to be collected during this visit: LIC 500, LIC 9020, LIC 308, LIC 400, LIC 402, LIC 610E, a copy of liability insurance, blank admissions agreement, updated facility sketch, and a copy of the Designated Facility Administrator's Certificate. The inspection began in the kitchen. All knives were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. LPAs observed packages of bread and leftovers that were not packaged and dated as required. LPA provided technical assistance. LPA compared the facility sketch to the current floor plan and they were identical with no changes. LPA inspected 6 resident bedrooms, 2 staff rooms and an office. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels, and trash cans in the 4 bathrooms. The hot water temperature was measured at 108 degrees Fahrenheit and was in compliance. The fire extinguisher was last serviced on 09/18/24 by Sentinel Fire Equip. Comp and was also in compliance. The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There were shaded areas in the front and rear of the building for residents to enjoy. LPA observed pesticides that were

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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: ELIXIR CARE HOME	FACILITY NUMBER: 342701336
	VISIT DATE: 04/22/2025

NARRATIVE

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left unattended in 2 places in the yard. The Administrator removed them immediately to ensure that they were inaccessible to residents in care. This deficiency was cited on the LIC 809D page.

The LPA observed medications were stored in a locked cabinet in the kitchen. LPA also observed some over the counter/staff medications in another unlocked cabinet. LPA explained that all medications need to be locked up and inaccessible to residents in care. This deficiency was also included in the citation on the LIC 809D page. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

A file review was completed by the LPAs. LPAs reviewed 2 resident and 2 staff files. The resident files were in compliance at the time of this inspection. LPA provided technical assistance stating that training needed to be documented in each of the staff files. Copies of completed annual online training had not been printed out. The Administrator stated they will be sent to Community Care Licensing by 05/02/25.

LPAs compared the LIC 500 (Staff Roster) with the Guardian roster to ensure that all staff had the appropriate background clearances to care for the residents. All were in compliance at the time of this inspection.

According to the California Code of Regulations, Title 22, any deficiencies that were cited during today's inspection were cited on the LIC 809D page.

A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2025 04:48 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 04/22/2025 at 04:17 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: ELIXIR CARE HOME	FACILITY NUMBER: 342701336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the LPA observed pesticides in 2 locations in the yard, toxic chemicals in an unlocked cabinet under the sink, and medications in an unlocked cabinet in the kitchen. These posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/23/2025
	Plan of Correction
1 2 3 4	The Administrator stated that they will replace the lock under the sink (as it was not locking easily) and they will relocate all medications into a designated space in the medication cabinet to ensure all items that could pose a threat to residents are kept inaccessible. Pictures of these changes will be sent to Community Care Licensing at CCLASCPSacramento@dss.ca.gov by the close of business tomorrow. The pesticides were removed from the facility.

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:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC809 (FAS) - (06/04)

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