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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005043
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:39:20 PM

Document Has Been Signed on 12/20/2024 12:39 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/
DIRECTOR:		CALAGUI, LANIFACILITY TYPE:
740
ADDRESS:8510 STONEFLOWER WAYTELEPHONE:
(916) 896-5185
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Joyce SmithTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) conduct an initial complaint visit. 27-AS-20241219093215 on 12/20/24 at 11:15a. LPA met with Joyce Smith, Caregiver and stated the purpose of the visit.

Joyce Smith contacted the Administrator regarding the purpose of the visit and that resident #1 (R1) file is not available for review. LPA spoke with Administrator regarding this deficiency.

LPA spoke with Administrator Lani Calagui who stated she is out of town and is not able to provide a copy of the file today.

Although the licensee understands the records are to be retained for a minimum of 3 years following termination of service to a resident, the records were not readily available for review during this visit and will not be ready during business hours today.

Based on admittance by the Licensee the records are not readily available for review or copying this will be cited today on this Case Management visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 809D during this visit.

Licensee was provided a copy of their rights (LIC9058) and their signature acknowledges receipt of these rights.

Exit interview held, a copy of report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 12:39 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/20/2024 at 12:02 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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure...record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Licensee shall submit a copy of R1's complete file to the office by 12/24/24 as well as a written statement indicating the Title 22 regulations will be upheld at all times.
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This requirement is not met as evidenced by:
Based on Confirmation from Licensee the file for R1 is unavailable for review or copying.
This poses a potential health and safety risk to 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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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