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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701163
Report Date: 04/11/2023
Date Signed: 04/24/2023 08:37:07 AM

Document Has Been Signed on 04/24/2023 08:37 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:RCFE CARE & RESPITE HOUSEFACILITY NUMBER:
392701163
ADMINISTRATOR:SANTIAGO, ROLANDOFACILITY TYPE:
740
ADDRESS:663 CHICAGO AVENUETELEPHONE:
(209) 207-4964
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 2DATE:
04/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rolando SantiagoTIME COMPLETED:
01:30 PM
NARRATIVE
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On 4/11/23 at approximately 10:25am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post licensing visit. LPA Jensen met with Licensee Rolando Santiago and explained the purpose of today's visit.

LPA Jensen toured the grounds and the physical plant. LPA Jensen observed all exterior paths to be clear and free of debris. LPA Jensen observed 3 window screens that need replacement as a result of being torn or missing. There are no bodies of water on the property.

The physical plant was observed to be sanitary and free of odor. There is sufficient furniture for the residents throughout the home. The facility maintains a large variety of activities for resident engagement and also has a designated activity room and exercise or physical therapy room. The thermostat was set at 70 degrees which falls within the required regulatory range of 68-85 degrees Fahrenheit. The water temperature measured at 116 degrees which falls within the required regulatory range of 105-120 degrees.

The facility maintains an adequate supply of linen and PPE. Toxins, medications and sharp objects were all observed to be locked and inaccessible to residents in care. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food.

LPA Jensen interviewed 2 of 2 residents both of whom stated all their needs are being met and they are satisfied with all aspects of care.

A deficiency is being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 04/24/2023 08:37 AM - It Cannot Be Edited


Created By: Maja Jensen On 04/11/2023 at 12:56 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RCFE CARE & RESPITE HOUSE
FACILITY NUMBER: 392701163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

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

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of 2 window screens that were torn and 1 screen that was missing 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: 05/09/2023
Plan of Correction
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Licensee agrees to replace any torn or missing window screen by plan of correction due date and will email photos of proof of correction to maja.jensen@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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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