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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:18:45 PM

Document Has Been Signed on 09/06/2023 04:18 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:
09/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lani CalaguiTIME COMPLETED:
04:30 PM
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On 9/6//23 at approximately 3:30PM Licensing Program Analyst (LPA) Jennifer Fain arrived at the facility unannounced to conduct a case management. LPA met with administrator and explained the reason for the visit. The facility is licensed for 6 residents and currently has 6 residents in care.

Based on LIC500, requested 8/30/23 and received 8/31/23, LIS Facility Personnel Printout and Guardian Employee Roster, Staff 1 did not appear to be associated with the facility.

LPA Fain reviewed the facility files for Staff 1 and found the faxed transfer request. LPA and Administrator discussed the need to confirm Facility Profile on Guardian lists employee name.

Pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code no deficiencies were cited today.

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: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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