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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700225
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:31:38 PM

Document Has Been Signed on 11/17/2022 04:31 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:MONA LIZAFACILITY NUMBER:
392700225
ADMINISTRATOR:SALEH, MOTHANNAFACILITY TYPE:
740
ADDRESS:1552 MIDDLE FIELD AVETELEPHONE:
(209) 910-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Mothanna Saleh via phoneTIME COMPLETED:
04:30 PM
NARRATIVE
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On 11-17-22 at 3:51pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding facility file documentation. LPA met with Mothanna Saleh via phone and explained the purpose of the visit. LPA also met with staff1 (S1) and S2 and explained the purpose of the visit. During a complaint investigation for complaint #27-AS-20221110163839, LPA reviewed incident report for resident1 (R1). It was revealed through interviews and record reviews R1 eloped from facility on 11-9-22, and the incident report was not sent to licensing department per regulatory requirements.

Based on today's case management visit, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with S1 and a copy of this report was left with S1. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 04:31 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/17/2022 at 04:20 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: MONA LIZA
FACILITY NUMBER: 392700225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
CCR
87211(a)(D)

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Reporting Requirements. (a)Each licensee shall furnish to the licensing agency such reports...including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, such as...unexplained absence of any resident.
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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This requirement is not met as evidenced by: Based on record review and interview, R1 eloped from facility on 11-9-22 and Licensee did not ensure a report was sent to licensing department per regulatory requirements. This posed 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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