<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:05:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/23/2021 01:05 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ARLYN'S GUEST HOMEFACILITY NUMBER:
392700049
ADMINISTRATOR:DE LA CRUZ, ARLYN MFACILITY TYPE:
740
ADDRESS:1633 S STOCKTON STREETTELEPHONE:
(209) 915-3962
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Arlyn De la CruzTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Arlyn De La Cruz and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications for each resident. There was medication unlocked through the facility. (They were locked during the inspection) LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. The staff files was missing a first aid / CPR card. Fire drill was completed on 7/2019.

All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. There is continued issues with deficiencies, therefore this facility will be referred to technically support. Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/23/2021 01:05 PM - It Cannot Be Edited


Created By: Albert Johnson On 06/23/2021 at 12:33 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2021
Section Cited
CCR
80023(d)(2)

1
2
3
4
5
6
7
Disaster and Mass Casualty Plan - Disaster drills shall be conducted at least every six months. The drills shall be documented and the documentation maintained in the facility for at least one year.
1
2
3
4
5
6
7
Administrator agrees to conduct a fire drill and maintain a fire safety log that will be available at the facility.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on records reviewed, care home states it is conducting fire drills but a log is not present in the facility. This poses a potential safety risk to the residents in care.
8
9
10
11
12
13
14
Administrator shall email a copy of the fire drill log along with a statement of understanding of this regulation to LPA by POC due date
Type B
07/09/2021
Section Cited
CCR80075(f)

1
2
3
4
5
6
7
80075(f) Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross.

No First Aid and CPR proof in file. Administrator could not provide proof for S1.
1
2
3
4
5
6
7
Administrator shall call a First AID vendor and requested a New Card or send by email proof. Administrator will send a copy of First Aid card to LPA. FAX (916) 263-4744
8
9
10
11
12
13
14
Based on records review S1 does not have a First Aid/ CPR Card.
8
9
10
11
12
13
14
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/23/2021 01:05 PM - It Cannot Be Edited


Created By: Albert Johnson On 06/23/2021 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARLYN'S GUEST HOME
FACILITY NUMBER: 392700049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited
CCR
87465(h)(2)

1
2
3
4
5
6
7
Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.
1
2
3
4
5
6
7
Administrator shall secure all medications in locked refrigerator or lock box by close of business of POC date.

LPA will conduct POC visit
8
9
10
11
12
13
14
This requirement was not met as evidencied by observation during the tour LPA observed medications in residents rooms, in the refrigerator, on the table and in the staff room. This is an immediate risk to residents in care.
8
9
10
11
12
13
14
Items were locked during the tour.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3