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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700935
Report Date: 02/03/2025
Date Signed: 02/04/2025 09:08:04 AM

Document Has Been Signed on 02/04/2025 09:08 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:BEATITUDES CARE HOMEFACILITY NUMBER:
392700935
ADMINISTRATOR/
DIRECTOR:		NOLASCO, RICKY C.FACILITY TYPE:
740
ADDRESS:1639 UNITED ST.TELEPHONE:
(209) 647-9701
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ricky NolascoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 02/03/2025 by Licensing Program Analyst (LPA) Charlie Yang.
This LPA was met by the facility designated Administrator, Ricky Nolasco, who was briefly interviewed at this time.
Current census was 4 residents.
It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (3) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there was (1) resident diagnosed with dementia at this time.
It was learned that there weren't any residents receiving services through home health at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured.
Additional food storage units were observed to be present and functional at this time.
Laundry room, located prior to the entrance for the garage, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, # 6057310740, for Ricky Nolasco was observed to have an expiration date of
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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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: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935
VISIT DATE: 02/03/2025
NARRATIVE
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09/08/2024 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time.
Medication cabinet, located in the facility kitchen cabinets, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the laundry room, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher that was located in the kitchen area was observed to have been annually purchased from the local Costco Company on 03/01/2024 and found to be in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (5) facility personnel records was conducted on the LIC 859.
A review of (4) facility resident records was conducted on the LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated representative at this time.
Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2025 09:08 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/03/2025 at 12:12 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: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [4] out of [5] facility staff files did not current certified First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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The facility designated Administrator stated that all facility staff providing care and supervision to the residents in care will be updated for training and be current in First Aid certification at all times. A statement of correction, along with copies of the updated First Aid certificates, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/04/2025 09:08 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/03/2025 at 12:12 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: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there was old and unused furniture items left out in the side yard which needed to be removed since it poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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The facility designated Administrator stated that the side yard will be cleaned and cleared of all unused furniture items. A statement of correction, along with photos of the cleared side yard, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


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