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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701163
Report Date: 09/05/2023
Date Signed: 09/11/2023 04:50:44 PM

Document Has Been Signed on 09/11/2023 04:50 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
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:
95206
CAPACITY: 6CENSUS: 4DATE:
09/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Bella and Amearo HivalgoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident that occurred on 8/31/2023. Later joined by Rachel Ray and Rolando Santiago.

LPA reviewed special incident report dated 8/31/2023 stating R1 had an unwitnessed fall and as a result sustained a Peri-orbital laceration.

R1 has a history of falls and the facility has taken precautions to minimize R1 from falling out of bed. However, R1 has an outdated IPP and the facility has requested a meeting to updated it's plan for R1 to ambulate around the facility with her own wheelchair or a walker. R1 moved in without any medical equipment including medical alert bracelet.

During today's visit, LPA reviewed R1's file, medical records related to the fall and IPP which is dated 5/31/2022 on 9/1/2023 the facility requested an emergency meeting for evaluation.


Exit interview was conducted with Staff.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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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