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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:49:46 PM

Document Has Been Signed on 04/04/2023 03:49 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: DATE:
04/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lani CalaguiTIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/4/23 at approximately 2:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a proof of correction visit. LPA Maja Jensen met with Licensee Lani Calagui and explained the purpose of today's visit.

On 3/23/23 Licensing Program Analysts Maja Jensen and Jennifer Fain conducted a required one year annual visit. During the course of the annual inspection it was determined that the admission agreements were out of compliance and a Plan of Correction was generated stipulating the admission agreements were to be updated so as to comply with the California Code of Regulations (CCR) Title 22, Division 6 and submitted to LPA Jensen via email by 3/30/23. The new admission agreements were not received by the due date. The Licensee showed LPA Jensen that the admission agreements were drafted but not have yet been signed. The Licensee advised that the new admission agreement drafts were faxed to the Department but the Licensee advised that the fax transmittal confirmations were not available at the facility.

While there were two separate citations issued for clauses in the admission agreements that were a violation of regulations both citations required the same Plan of Correction which is new, revised admission agreements signed by responsible parties for all residents, therefore only 1 civil penalty is being assessed for failure to correct a deficiency by the Plan of Correction due date.

Also during the course of the site visit LPA Jensen tested the water temperature in the bathroom located in the bedroom hallway. The water temperature measured at 100.5 degrees Fahrenheit at the highest reading, this falls outside of the required range of 105-120 degrees. A deficiency for water temperature is being cited from CCR, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of additional civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given to Licensee.





SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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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Document Has Been Signed on 04/04/2023 03:49 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/04/2023 at 03:24 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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation...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 degree C) and not more than 120 degree F (49 degree C). This rfequirement was not met as evidenced by:
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Licensee agrees to conduct a daily water temperature reading and log results. Licensee will email a weekly log to maja.jensen@dss.ca.gov for 4 weeks beginning 4/12/23.
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Based on LPA Jensen's measurements of the water temperature in the bedroom hallway bathroom of 100.5 degrees or less. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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