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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701000
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:35:32 PM

Document Has Been Signed on 09/26/2024 01:35 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:VILLA THERESA 2 CARE HOMEFACILITY NUMBER:
392701000
ADMINISTRATOR/
DIRECTOR:		ALAN, JOSE FFACILITY TYPE:
740
ADDRESS:3028 MCCOOK WAYTELEPHONE:
(209) 462-4239
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Sharon Fernandez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 09/26/2024.  LPA Campbell met with Sharon Fernandez, House Manager and Administrator and explained the purpose of the visit.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and the backyard of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) ambulatory residents and there is a hospice waiver for three (3). LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured in the kitchen and bathroom. The kitchen water temperature measured at 109.6 degrees and the resident bathroom water temperature measured at 109.4 degrees. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. The fire extinguisher was last inspected on 07/25/2024. The facility thermostat was observed at 73 degrees Fahrenheit. LPAs checked medication storage and found medication to be locked away and inaccessible to clients in a kitchen pantry. The First aid kit was incomplete and was missing a tweezer that was provided during the visit. LPA Campbell requested client and staff files for review. LPA Campbell reviewed 4 of 4 resident files and 4 of 10 staff files. Of the 4 files reviewed, 2 of them were missing Personal Rights documentation. Staff files were complete. Toxins were made inaccessible to clients in care. Toxins were stored in a locked cabinet in the laundry room.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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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: VILLA THERESA 2 CARE HOME
FACILITY NUMBER: 392701000
VISIT DATE: 09/26/2024
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The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 09/30/2024 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate  (once the new one is received by Administrator) 
(4) LIC 610 Emergency Disaster Plan
(5) LIC 9282 Infection Control Plan



Per California Code of Regulations, Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil penalties.

An exit interview was conducted and a copy of this report was left with the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2024 09:46 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/01/2024 09:37 AM


Created By: Renee Campbell On 09/26/2024 at 12:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA THERESA 2 CARE HOME
FACILITY NUMBER: 392701000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
87468 (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:
(1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.
(A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
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 2 out of 4 files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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The Administrator of the facility will provide a signed statement of understanding for the regulation above and have the residents and their representatives review and sign the Personal Rights form LIC613-C. Verification of both actions will be sent to LPA Campbell at renee.campbell@dss.ca.gov.
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:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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