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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701163
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:31:35 AM

Document Has Been Signed on 01/09/2024 11:31 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:
95206
CAPACITY: 6CENSUS: 2DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:ROLANDO SANTIAGO - ADMINISTRATORTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with Administrator and explained purpose of visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, client bedrooms; client 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. LPA measured the hot water temperature in client's bathroom at degrees Fahrenheit which is within the required range of 105 to 120 degrees.

Fire extinguishers last inspected on 2/8/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 12/26/2023.

Licensee has been following restricted health care plan approved on 4/14/2023 for client - C2 (See LIC 811 Confidential Names). Valley Mountain Regional Center (VMRC) service coordinator has documented C2's continual refusal of medications for condition of diabetes on individual program plan last documented on 12/5/2023. Therefore no need for deficiency for not following restricted health care plan. Primary doctor, VMRC, and client are aware of the health risk factors involved.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 392701163
VISIT DATE: 01/09/2024
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Continued from 809 - Page 2


LPA reviewed two client files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA received the following updated documents on today's date:
LIC 308 - Designation of Administrator, Copy of Surety Bond with Expiration Date, and Copy of Administrator Certificate.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit.

Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) were left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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