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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 03/23/2023
Date Signed: 03/23/2023 05:46:05 PM

Document Has Been Signed on 03/23/2023 05:46 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:ELITE ELDERLY CARE HOMEFACILITY NUMBER:
347005043
ADMINISTRATOR:CALAGUI, LANIFACILITY TYPE:
740
ADDRESS:8510 STONEFLOWER WAYTELEPHONE:
(916) 896-5185
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Grace MataTIME COMPLETED:
05:45 PM
NARRATIVE
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On 3/23/23 at approximately 2:15pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a required one year annual visit. LPAs Jensen and Fain met with Administrator Grace Mata and explained the purpose of the visit. The Administrator holds current certificate # 6065133740 good through 12/20/2024.

LPAs Jensen and Fain toured the facility The facility currently has 5 residents and provides dementia care. The grounds were observed to be well maintained and all paths were clear of debris. Two windows were observed to have torn screens and the dining room screen was determined to be missing. The facility was observed sanitary and free of odor. The carbon monoxide detector was tested and determined to be in good working order. The fire extinguisher was last serviced in December of 2022 and is in compliance. The first aid kit was determined to be complete with scissors, tweezers, thermometer and manual. The bathroom was observed to have grab bars at the toilet and shower. he bathtub was observed to have a non-slip mat. There are night lights set up in the hallway leading to the residents bathroom. The water temperature in the bathroom was measured at 119.5 degrees which falls within the required regulatory range of 105-120 degrees. The thermostat was set at 71 degrees for the comfort of the residents. The facility maintains a sufficient supply of linen.

The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was fresh fruit and vegetables available for residents in care. The facility caters meal service to each resident's preference. All knives, toxins and chemicals were observed to be locked and inaccessible to residents in care.

Continued on LIC 809C....

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ELITE ELDERLY CARE HOME
FACILITY NUMBER: 347005043
VISIT DATE: 03/23/2023
NARRATIVE
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The facility emergency disaster plan was reviewed and is in compliance. The facility conducts fire drills monthly.

LPA Jensen reviewed 5 of 5 resident files. 2 of 5 resident admission agreements state that at least 30 days notice will be given for general rate increases. 3 of 5 resident admission agreements state that at least 10 days notice will be provided for a general rate increase which contradicts regulatory requirements in the Health and Safety Code §1569.655(a). 4 out of 5 resident admission agreements state that no refunds shall provided upon the death of a resident which contradicts regulatory requirements in the Health and Safety Code §1569.652(c).
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LPA Jensen determined that annual licensing fees have been delinquent since 2019.

LPA Jensen requested a copy of the liability insurance and an updated LIC 500 be emailed to maja.jensen@dss.ca.gov by 3/27/23.

Deficiencies are being cited from the Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/23/2023 05:46 PM - It Cannot Be Edited


Created By: Maja Jensen On 03/23/2023 at 04:45 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELITE ELDERLY CARE HOME
FACILITY NUMBER: 347005043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185

The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's record review of payment history, the licensee has not paid annual fees since 2019 and therefore the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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Licensee will submit proof that annual licensing fees have been paid and are current to maja.jensen@dss.ca.gov by plan of correction due date.
Type B
Section Cited
HSC
1569.655

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's review of resident files and Admission Agreements, the licensee did not comply with the section cited above in 5 of 5 counts, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Licensee agrees to create new admission agreements and have them signed by all residents responsible parties within 7 days. The new signed agreements will be emailed to maja.jensen@dss.ca.gov by the Plan of Correction due date.
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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/23/2023 05:46 PM - It Cannot Be Edited


Created By: Maja Jensen On 03/23/2023 at 05:04 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ELITE ELDERLY CARE HOME
FACILITY NUMBER: 347005043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.652(c)

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's review of resident Admission Agreements, the licensee did not comply with the section cited above in 4 of 5 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Licensee agrees to have new admission agreements signed by all residents responsible parties and will email the admission agreements to maja.jensen@dss.ca.gov by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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