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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701511
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:10:58 PM

Document Has Been Signed on 10/21/2024 03:10 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:ELDERLY GUEST HOMEFACILITY NUMBER:
342701511
ADMINISTRATOR/
DIRECTOR:		SERRANO, ERICFACILITY TYPE:
740
ADDRESS:8774 KELSEY DRIVETELEPHONE:
(916) 304-3575
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Eric SerranoTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with facility administrator Eric Serrano and explained the purpose of the visit.

LPAs Moleski and Williams reviewed facility files and obtained copies of resident records pertaining to five residents (R1-R5).

Two residents diagnosed with dementia (R1, R3) had LIC 602s on file with exam dates more than one year in the past. R1's LIC 602 indicated that R1 was examined by a physician on 4/3/23. R1 has dementia, according to the LIC 602. R3's LIC 602 indicated that R3 was examined by a physician on 9/27/22. R3 has dementia, according to the LIC 602.

Serrano could not produce a more recent LIC 602 for either of these residents during this visit.

This facility is hereby cited per 22 CCR Section 87705(c)(5). An exit interview was held with Serrano. Appeal rights and a copy of this report was left with Serrano.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 03:10 PM - It Cannot Be Edited


Created By: Vincent Moleski On 10/21/2024 at 02:53 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: ELDERLY GUEST HOME
FACILITY NUMBER: 342701511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2024
Section Cited
CCR
87705(c)(5)

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" (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with updated LIC 602s by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review, two dementia residents did not receive annual medical assessments, which poses a potential health and safety risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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