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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700935
Report Date: 02/24/2022
Date Signed: 03/22/2022 09:51:56 AM

Document Has Been Signed on 03/22/2022 09:51 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BEATITUDES CARE HOMEFACILITY NUMBER:
392700935
ADMINISTRATOR:NOLASCO, RICKY C.FACILITY TYPE:
740
ADDRESS:1639 UNITED ST.TELEPHONE:
(209) 647-9701
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ricky Nolasco and Shannon McGurkTIME COMPLETED:
03:30 PM
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Unannounced annual visit made out to this facility on 02/24/2022 by LPA Charlie Yang who was met by the facility live-in caregiver Shannon McGurk. This LPA requested that she go ahead and contact the facility designated Administrator to inform him/her that CCL was present at this time. The facility designated Administrator, Ricky Nolasco, arrived shortly thereafter while LPA Yang was conducting this annual visit.
Administrator certificate was reviewed for Ricky Nolasco and observed to have been renewed on 09/29/2020 and in compliance at this time with a renewal date of 09/28/2022.
Current census was 5 residents of which there weren't any residents under the care of hospice and no residents were under the care of home health. This facility does have an approved hospice waiver to accept and retain up to (3) hospice residents.
Tour of the facility was conducted.
Kitchen area was toured. Drawers and cabinets were reviewed. Cook ware, dinnerware, and utensils were observed to be sufficient and able to meet the needs of the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities.
Medication cabinet, located in kitchen area, was reviewed. A sample of the resident medications was compared with the facility Medication Administration Record and dispensing log initialed by the facility staff.
First aid kit was reviewed for required components and observed to contain all necessary components at this time.
Fire extinguisher, located under the kitchen sink, was observed to have been annually purchased and observed to be in compliance at this time.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in good repair at this time.
A tour of the facility resident rooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935
VISIT DATE: 02/24/2022
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Grab bars were observed to be present and functional at this time.
Laundry area was toured. Detergents, bleach, and other cleaning agents were observed to be stored and maintained in a separate closet which was locked and made inaccessible to the residents at this time.
Linen closet was observed to contain a sufficient amount of linens and towels sufficient to meet the needs of the residents at this time.
Garage area was toured. It was learned that this area was used to store and house cleaning supplies and laundry supplies.
A tour of the exterior grounds was conducted.
Facility perimeter fence, side gates, and exits were reviewed.

The following forms were requested to be updated and submitted into CCL upon completion:

LIC 308

LIC 400

LIC 500

LIC 610

There weren't any deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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