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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 11/25/2024
Date Signed: 11/25/2024 04:19:11 PM

Document Has Been Signed on 11/25/2024 04:19 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:NOVELLUS STOCKTONFACILITY NUMBER:
392700997
ADMINISTRATOR/
DIRECTOR:
CHANTLLE HUDSONFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 160CENSUS: 50DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Gretchen Monares(LVN)TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with G Monares (LVN) and explained the purpose of the visit.

LPA inspected the physical plant with G. Monares including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour LPA observed broken ceiling panels, exposed wires and rat dropping. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. The fixed system in the kitchen is out of compliance and needs servicing. The last service date was 7/18/2023 this requires a semi-annual servicing. Citation and civil penalty assessed.

LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprinted and cleared. First aid kit was checked and is complete. Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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Document Has Been Signed on 11/25/2024 04:19 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/25/2024 at 12:51 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: NOVELLUS STOCKTON

FACILITY NUMBER: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:Observation of rat droppings,missing or broken ceiling panels
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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The facility will clean rat dropping and repair or replace ceiling panels by 12/13/2024
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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/25/2024 04:19 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/25/2024 at 01:15 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: NOVELLUS STOCKTON

FACILITY NUMBER: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire safety

This requirement is not met as evidenced by: Observation the fixed system/ ansul system is out of compliance and has not been serviced as required by the State fire marshal
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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The facility will repair or replace the fixed system to be in compliance with the state fire marshal requirement by the POC date 11/26/2024. The facility will submit a plan to repair the system by POC date 11/26/2024.
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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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