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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:37:41 PM

Document Has Been Signed on 08/30/2023 02:37 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 - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lani CalaguiTIME COMPLETED:
01:00 PM
NARRATIVE
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On 8/30/23 at approximately 10am, Licensing Program Analysts (LPAs) Jennifer Fain and Kesha Lewis arrived unannounced to conduct a Health and Safety Check/ Quarterly Visit. LPAs met with Lani Calagui, the administrator and explained the reason for the visit.

On arrival several residents were watching tv in the common area. One resident was visiting with a home health nurse, One resident was in the living room on his phone. One resident was visiting with family and having a therapy visit for new admission assessments.

LPA Checked the following areas per Noncompliance conference:
Hire additional staff or begin utilization of staffing services by 5/9/2023
*** Two live in staff have been hired, two additional staff on call
Submit a water heater repair or replacement invoice by 5/9/2023
****Water heater repaired. Water temperature was 106.9 degrees Fahrenheit. Licensee is keeping a water temperature log.
Conduct a self-audit of resident files and ensure all files are in compliance by 6/1/2023
**** Files were missing several components. Licensee stated she had requested TSP for file review at the Noncompliance Conference (NCC). 809 from conference does not state TSP was requested. LPA Fain will request TSP for Licensee.
Administrator to complete an additional 10 hours of training on regulation compliance by 6/1/23 **** Hours completed and certificates received 8/16/23


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 to Lani Calagui.
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)
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Document Has Been Signed on 08/30/2023 02:37 PM - It Cannot Be Edited


Created By: Jennifer Fain On 08/30/2023 at 12:46 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: ELITE ELDERLY CARE HOME
FACILITY NUMBER: 347005043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87623(a)(1)(A)

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(A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders.
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Licensee states she will request an exception for cathether by POC date of correction. Request will be emailed to LPA Fain at jennifer.fain@dss.ca.gov
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Based on observation and interview R(1) has a catheter. S(1) states training in catheter care has not occured.This poses an imediate risk to residents in care.
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Type A
08/31/2023
Section Cited
CCR87705(c)(4)(a)

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..., a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal .... This requirement was not met as evidenced by:
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Licensee states she will send an updated schedule reflecting the dementia requirement by close of business on POC date. Proof should be sent to jennifer.fain.dss.ca.gov Licensee states that she will be awake staff tonight.
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Based on obervation, interview and file review, the live in staff sleep through the night waking 1-2 times for resident checks.
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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:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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