392700264-4-16-2026-27-AS-NWPN-DT7LH6-20260416084549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700264
Report Date: 04/15/2026
Date Signed: 04/16/2026 08:46:37 AM

Document Has Been Signed on 04/16/2026 08:46 AM - 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: 6	DATE:	04/15/2026
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Monica Plowden		TIME VISIT/ INSPECTION COMPLETED:	02:40 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	A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 will be provided to the licensee. Parties in attendance of this meeting are documented on the LIC 9111. On April 15th 2026, a meeting was held at 2pm regarding recent noncompliance with regulation at the facility Jewell Care Home with 3 agenda items: Incident: In the past year, a client of the facility was hospitalized in relation to widespread bruising with an unknown origin. Shocking to the department was that there was documentation from the staff that it was internally reported but the internal reporting didn’t make it to Licensing. Staffing: As part of an investigation by the department into the above event, the staffing of the facility appears to have one staff present for all of three of both Saturday and Sundays shifts. It's unclear that the staff receive adequate coverage for breaks and adequate uninterrupted rest between shifts where they are expected to not be on call. Administrator staffing: Separate from adequate numbers of staff, its unclear the administrator is spending adequate time in the facility to observe the staff performing basic functions, training, and assessing staff. Continued on C page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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: 04/15/2026

NARRATIVE

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Issues discussed related to the above include:

Facility plans regarding mandated reporter training and staff coverage
Staffing in the facility regarding incontinance/rotation, hiring a new staff
Numbers of bedridden currently at the facility, how does hospice count for bedridden?
Quarterlys, where the implementation of the agreed upon section below will be observed by an LPA.

During the meeting, the facility agreed to the following: (highlighted are standard asks)
   1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 4-22-26.
   2. Conduct Mandatory Reporter training within 6 months then annually
   3. Provide a Plan for the administrator to be observing and assessing the staff in the performance of their duties for the facility by 4-22-26

Provide a job posting for a new hire to 4-22-26

CCL will:
Conduct unannounced quarterly visits to monitor the overall compliance. Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking action(s). During these visits, the Department will focus its review on the following areas in addition to the above:

~Individualized Needs and services plans updated quarterly for all clients documenting the facilities obligations,
~Contracts on file describing obligations as needed for clients with Home Health and Hospice Care,
~Staff knowledge regarding reporting requirements, restricted and prohibited care conditions

In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.

The meeting concluded at 2:40pm. A copy of the report and the 9111 were read to the licensee and an exit interview was conducted via telephone. a copy of this report and the 9111 were sent electronically for signature.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC809 (FAS) - (06/04)

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