<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701252
Report Date: 07/03/2023
Date Signed: 07/05/2023 01:01:36 PM

Document Has Been Signed on 07/05/2023 01:01 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:YANNICA GUEST HOME 1FACILITY NUMBER:
392701252
ADMINISTRATOR:MARTIN, MAXIMAFACILITY TYPE:
740
ADDRESS:3519 NOVARA WAYTELEPHONE:
(510) 366-6585
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maxima Martin, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/03/2023 at approximately 12:30 pm, Licensing Program Analysts (LPA) Renee Campbell and Victoria Brown arrived unannounced to the facility to conduct a Post-Licensing visit and met with Maxima Martin, Administrator. LPA's stated the purpose of the visit. Facility has 5 residents. Licensee Maxima Martin has four staff members (in addition to herself) who work for the facility. LPA Campbell requested 2 of 4 staff files and 3 of 5 resident files for review.
LPA's toured the facility physical plant to include the kitchen,living rooms, bathrooms, dining rooms and outside area.

LPA's observed perishables to last two days and non-perishables to last 7 days. Knives and cleaning supplies were locked. All rooms were found to contain a bed, night table and lamp and were well lit for the comfort and safety of the residents. The thermostat was set at a comfortable temperature of 73 degrees Fahrenheit and water temperature was measured at 106 degrees Fahrenheit. The fire extinguisher was last inspected on 02/09/23. A first aid kit was found to be complete and medicines were separated by client names.

The backyard area was observed to have a shaded seating area. No bodies of water were found. All staff had CPR/1st Aid Training. All indoor passageways were free of obstruction. All staff are associated to the facility.
The following forms to be updated and submitted to CCL by 07/10/2023:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
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 3
Document Has Been Signed on 07/05/2023 01:01 PM - It Cannot Be Edited


Created By: Renee Campbell On 07/03/2023 at 03:14 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: YANNICA GUEST HOME 1
FACILITY NUMBER: 392701252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)


This requirement is not met as evidenced by: LPA observed a filled 7 day pill box for all resident.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above and 5 out of 5 pill boxes were found to be in 7 day pill dispensers which poses a immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
1
2
3
4
Administrator will write a statement of understanding for regulation 87465(h)(5) and will fax the document to LIcensing Program Analyst Renee Campbell. In addition, inservice for all staff to be completed by 07/10/2023
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Emerita Curiel
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: YANNICA GUEST HOME 1
FACILITY NUMBER: 392701252
VISIT DATE: 07/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(cont) Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3