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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700049
Report Date: 01/04/2022
Date Signed: 01/04/2022 07:19:52 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/04/2022 07:19 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:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Nieves ConcepcionTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Nieves 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. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. During the resident files review LPA observed that R1 had a fall on 1/2/2022 further investigation determined that R1 had a visit to the ER on 11/3/2021 for a foot injury, this was not reported to the department. The facility is also out of compliance with service plans for 3 of 6 files reviewed. Fire drill was completed on 6/24/2021.

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: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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 01/04/2022 07:19 PM - It Cannot Be Edited


Created By: Albert Johnson On 01/04/2022 at 02:06 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: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2022
Section Cited
CCR
87705(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
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Licensee agrees to submit a plan of correction to LPA by 1/14/2022 on how R1 and R2's annual appraisal will be completed.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in (2) out of (2) residents diagnosed with dementia which poses/posed a potential health and safety risk to persons in care.
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Type B
01/14/2022
Section Cited
CCR87463(c)

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any,
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The facility shall obtain a current Needs and Services Plan for R1 thru R3.
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when there is significant change in the resident’s condition, or once every 12 months, LPA observed Needs and Services Plan is outdated for R1 thru R3.
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Written certification stating administrator has read regulation 87463 along with copies of current Needs and Services Plan to be sent to CCLD by POC date
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: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022


LIC809 (FAS) - (06/04)
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