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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:48:29 PM

Document Has Been Signed on 11/15/2023 12:48 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: 4DATE:
11/15/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lani CalaguiTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/15/23 at 9:30am to conduct a Case Management visit. LPA met with Lani Calagui and stated the purpose of the visit.

LPA obtained information that the staffing services agencies that the licensee contacted were over priced. The Licensee hired 4 additional staff but 1 left after 1 month making the decision the job was not a good fit. An email dated 5/23/23 was sent to LPA Maja Jensen indicating the staff requirement has been met.

LPA observed an email which included a photo and invoice submitted to Maja Jensen, LPA dated 5/9/23 that the water heater was repaired. This submission met the Departments requirement.

LPA observed files of 4 residents and 4 staff for any compliance issues during this visit.

LPA also observed an email sent to Maja Jensen, LPA dated 6/1/23 as well as Jennifer Fain, LPA on 8/29/23 as proof that the additional 10 hours of Administrator training on regulations was completed.

LPA conducted a tour of the physical plant and observed the residents during this visit. LPA did not observe hazards to residents during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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