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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005043
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:46:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20241219093215
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:
02/12/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lani CalaguiTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff dropped resident during transfer resulting in serious head injury
Licensee did not answer communications from resident's family appropriately
Licensee restricted resident from having visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 2/12/25 at 3:30pm to conclude the investigation of the above mentioned allegations. LPA met with Lani Calagui and stated the purpose of the visit.

Regarding allegation, “Facility staff dropped resident during transfer resulting in serious head injury” the Department obtained medical records which indicated that on 9/5/23 911 was initiated and R1’s family was present at which time R1 admitted transferring from walker to recliner when tripped over feet and fell on right side. This was witnessed by staff. The admitting diagnosis was accidental fall. R1 was discharged 9/7/23 to skilled nursing facility.
Unsubstantiated
Estimated Days of Completion: 120
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20241219093215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 347005043
VISIT DATE: 02/12/2025
NARRATIVE
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Regarding allegation, “Licensee did not answer communications from resident's family appropriately” LPA obtained information through interviews that the licensee did speak with the family when asked where was R1, however, because the family moved R1 out unexpectedly, the Licensee did not know where R1 was residing.

Regarding allegation, “Licensee restricted resident from having visitors” LPA obtained information through interviews on 12/19/24 with LTCO and a review of documentation that R1 made a list of people who R1 allowed to visit the facility.

Based on documentation review and interviews the allegation(s) are UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2