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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 02/25/2026
Date Signed: 02/25/2026 07:25:35 PM

Document Has Been Signed on 02/25/2026 07:25 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 CAREFACILITY NUMBER:
392700264
ADMINISTRATOR/
DIRECTOR:		RALH, MONICAFACILITY TYPE:
740
ADDRESS:1141 S. VAN BUREN STREETTELEPHONE:
(209) 323-4972
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
02/25/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:54 PM
MET WITH:Monica PlowdenTIME VISIT/
INSPECTION COMPLETED:
06:55 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
On 2/25/25 at 6:30, LPA Wolf Petersen arrived to conduct a case management related to the findings of a complaint. LPA met with administrator Monica Plowden by phone to explain the findings of a departmental report.

In interview, staff provided a statement that they were insufficiently following facility procedures and regulatory requirements to report the bruises and follow up with seeking medical attention.

In record review of the medical reports generated from the 10/28/25 visit related to bruising, R1 was diagnosed with both a uti and obstruction.

LPA gave guidance that staff should document changes in status, to include bruising. If its reasonable to suspect that physical abuse is occurring, the facility should be reporting to licensing, the ombudsman, and local law enforcement within 24 hours via an IR, telephone call and SOC341. If its reasonable to suspect medical attention is required, the facility should be arranging for medical care. Observation of resident and changes in mood, condition or functional ability should be reported to the physician and if necessary appropriate medical intervention sought in a timely manner. Having hospice does not preclude the licensee from seeking timely medical attention.
The Department is Requesting the 602, any Hospice Care Plan, and any Home Health Plan, for all residents currently in the facility. Provide to the lpa via email: noel.wolfpetersen@dss.ca.gov. 3/6/25


Citation(s) are issued, A copy of the report was read, appeal rights and the copy of the report was given to the administrator. 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: 02/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2026
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
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)
Page: 2 of 3
Document Has Been Signed on 02/25/2026 07:25 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 02/25/2026 at 06:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JEWELL HOME CARE
FACILITY NUMBER: 392700264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2026
Section Cited
CCR
87466(a)

1
2
3
4
5
6
7
87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
1
2
3
4
5
6
7
No Immediate POC required: the resident at risk was already removed from the facility. Licensee will conduct a training on the division of labor for hospice care and the facility, when its appropriate to use the hospice care nurse versus when its appropriate to use medical services. Licensee will update their Plan of Operation to address this in detail. training by 3/25/26. updates to the plan of Op by 3/13/26
8
9
10
11
12
13
14
This requirement was not met as evidenced by: interview where staff had applied an ointment to the bruising, and upon proving ineffective over two applications, reported bruising to the hospice care nurse instead of making arrangements for the client to go the hospital. Record review of the hospice care plan, where severe widespread bruising is not described as a responsibility of the hospice care agency. Record review of a residents medication history, where the client has not taken blood thinners.
Not following this requirement poses an immediate risk to the health, saftey, and personal rights clients in care.
8
9
10
11
12
13
14
Type A
02/26/2026
Section Cited
CCR87211(c)

1
2
3
4
5
6
7
87211(c) Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
1
2
3
4
5
6
7
No Immediate POC required: the resident at risk was already removed from the facility. All staff shall participate in Mandated Reporter Training . Send the LPA evidince of a training(trainings) scheduled with a contact for a vendored trainer, by 3/25/26
8
9
10
11
12
13
14
This requirement was not met as evidenced by: interview where a staff had noticed mysterious bruising coinciding with home health aide visits in months previous to a complaint incident in october 2025, record review of the internal staff log where a vague documentation of the event exists in september 2025 and statements by the staff pertaining to the current investigation.
Not following this requirement poses a immediate risk to the health, safety, and personal rights clients in care.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


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