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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700225
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:49:45 PM

Document Has Been Signed on 02/27/2023 12:49 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:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Maciu VavaTIME COMPLETED:
01:00 PM
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On 2-27-23 at 10:43am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Maciu Vava, lead caregiver and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly (RCFE) with a current census of 5. Facility has 4 bedrooms and 2 bathrooms for resident use. There is a dining area off the kitchen. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors as necessary. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, and on the front door. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. 5 resident charts were reviewed. Staffing files were not at facility during today's visit. Cleaning supplies were observed by LPA to be located in kitchen, unlocked, and accessible to residents in care.

Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 69*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was fully charged. Facility has an emergency food and water kit. LPA requested updates for LIC 500 and LIC 308.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Maciu Vava
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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 02/27/2023 12:49 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/27/2023 at 11:55 AM
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: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2023
Section Cited

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Storage Space. (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Based on LPA observation, various cleaning solutions were unlocked under the sink and accessible to residents in care. This poses an immediate health and safety risk to residents in care.
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Licensee or designee will submit a plan on how all toxic and other dangerous items will remain inaccessible to residents in care. Plan to be submitted to LPA by POC due date.
Type B
03/10/2023
Section Cited

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Personnel Records. (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
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Based on interview and observation, personnel records requested were not on site during today's visit and available for LPA to review. 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023


LIC809 (FAS) - (06/04)
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