392700264-11-4-2025-27-AS-NWPN-DN4UW2-20251104145602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 11/04/2025
Date Signed: 11/04/2025 02:56:09 PM

Document Has Been Signed on 11/04/2025 02:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	JEWELL HOME CARE		FACILITY NUMBER:	392700264
ADMINISTRATOR/ DIRECTOR:	RALH, MONICA		FACILITY TYPE:	740
ADDRESS:	1141 S. VAN BUREN STREET		TELEPHONE:	(209) 323-4972
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 3	DATE:	11/04/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Monica Ralh		TIME VISIT/ INSPECTION COMPLETED:	03:00 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, Noel Wolf Petersen arrived unannounced to conduct a case management regarding an incident that occured at Jewell Home Care, the staff had noticed some facial bruising on a client on sunday 10/26/25 that exacerbated into a concerning size and shape by monday 10/27/25, which was reported by a Home Health Aid working for A Plus Prime Care Hospice, INC, a hospice agency, on the 10/28/25 tuesday. Police were called out and Adult Protective Services moved the client. Jewel Home Care is a 6 bed facility for the elderly that includes dementia support with a maxiumum of 3 residents on hospice, there are currently 1 residents with hospice, one has wound care, and 2 non ambulatory residents. LPA Wolf Petersen asked for any documentation regarding the incident in hospice care notes, The facilitiy internal care notes. Document review for the facility internal care notes is sparcely detailed, but indicates that some bruising appears to be recognized in a timing pattern that coincideds with a bathing service performed by a Home Health Aid working for PrimeCare from september on to the present. Interview with the staff does not indicate that they were trained to document changes in status(i.e. bruising), while they are up to date with mandatory training hours and topics of general rcfe care, care specific to hospice clients, and care specific to dementia clients. All staff interviewed denied interacting with the client in a way that would be consistant with the griping of the face pattern of bruising that was observed. All staff interviewed note not being concerned with the bruising until monday morning, and while concerned they decided not to contact the hospice care agency for a variety of reasons,(the hospice nurse will be coming out the next day, the hospice nurse is not willing to do anything) continued on c Page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JEWELL HOME CARE	FACILITY NUMBER: 392700264
	VISIT DATE: 11/04/2025

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Client was noted in hospice initial assessment to have a confused temperament and expressive of resistance to being repositioned during diaper changes. Current medication at the time of the incident back to september includes a blood thinner. Facility copies of the Hospice care notes surveyed, does not have any indication of bruising in the narrative section.

Hospice care plan revised 10/14/25, indicates that training will be provided on skincare to the family/PrimaryCareGiver, administrator interview provides that the Hospice care plan did not follow through with the training noted on the hospice care plan to be provided by 10/31/25. and was not provided in that time.

The LPA is providing guidance that improving note taking procedures for changes of status between shifts and coordinating note taking procedures for changes of status from visiting agency representatives would be a good idea moving forward. Timely medical intervention should occur if the concern is not related to hospice, while an expanding area of internal bleeding isn't life threatening, it would be a good idea to get a medical evaluation of some kind.

No citations are issued as part of this visit, a copy of the Report was read and given to the administrator. The LPA asked for all the hospice narratives for the last 2 months. an exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

LIC809 (FAS) - (06/04)

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