<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:35:33 PM

Document Has Been Signed on 08/30/2023 02:35 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: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: 6DATE:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lani CalaguiTIME COMPLETED:
02:30 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
On 8/30/23 at approximately 1pm Licensing Program Analysts (LPAs) Jennifer Fain and Kesha Lewis arrived at facility unannounced to conduct a case management. LPAs met with Licensee Lani Calagui and explained the purpose of today's visit.

LPA Fain conducted interviews with 2 of 6 clients. Lunch was observed. 4 of 6 clients dined at the table together. One resident ate at the table before the larger group sat down to eat. After lunch residents watched a film, used their phone to watch tv or rested. LPA observed resident kiss staff on the check on walk through the residence. LPA heard staff praised for their care and gentleness.

Resident 2 (R2) stated that family had visited several times since admission to the facility. R2 stated that there were complicated family dynamics and that she had a list of family members that were welcome to visit. Staff 2 (S2) stated that R1 often gets calls that she does not choose to answer.

No Deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Licensee.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1