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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 03/01/2022
Date Signed: 03/01/2022 05:04:25 PM

Document Has Been Signed on 03/01/2022 05:04 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:COURTYARD AT RIO LAS PALMAS, THEFACILITY NUMBER:
392700640
ADMINISTRATOR:GUERRERO, LIZETHFACILITY TYPE:
740
ADDRESS:877 EAST MARCH LANETELEPHONE:
(209) 957-4711
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 80CENSUS: DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lizeth GuerreroTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Maja Jensen called facility prior to arrival at 9:30am to conduct COVID-19 screening questions and confirmed there are no active COVID cases in the facility. Licensing Program Analysts (LPAs) Maja Jensen and Avelina Martinez arrived at the facility unannounced at 9:45am to conduct a reuired 1 year annual visit and met with Administrator Lizeth Guerrero. LPAs explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 80 non ambulatory residents, today's census is 63, 9 hospice residents in compliance with licensure and fire clearance. 6 of 6 staff observed cleared and associated in Licensing Information System. Administrator certificate expires on 6/19/2022.

LPA interacted with a random number of residents during this visit and observed residents engaging in communal dining and activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, staff offices, and common restrooms. LPA observed facility last conducted disaster drill on 6/30/2021. The temperature inside the facility was measured at 76*F is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. The hot water was measured at 118*F which is not less than 105*F and not more than 120 *F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed two MAR's to document medications administered per physicians order. The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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