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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701351
Report Date: 01/28/2026
Date Signed: 01/28/2026 06:35:04 PM

Document Has Been Signed on 01/28/2026 06:35 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:CELY'S CARE HOME LLCFACILITY NUMBER:
392701351
ADMINISTRATOR/
DIRECTOR:
CECILIA REYESFACILITY TYPE:
740
ADDRESS:2372 BLUE TEES DRIVETELEPHONE:
(209) 986-4632
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 3DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Cecelia ReyesTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to conduct the annual inspection, LPA met with the Facility Administrator Cecelia Reyes. the facility is licensed for 6 nonambulatory one of which may be 1 bedridden. There are 1 client has o2 administration, 2 have diabeites, 3 have dementia. 3 are non-ambulatory. There is not an exception on file for the o2 administration insulin dependant diabetes, Administrator will work the LPA to file the exeption paperwork, begining with a formal request for an exception to be recived by the LPA in writing, noel.wolfpetersen@dss.ca.gov by end of day tomorrow 1/29/2026

Physical inspection includes a converted garage, there are 4 rooms, Bedridden room on the facility sketch is designated as room 3 or room 4. Physical inspection included the kitchen, bedrooms, bathrooms, common areas, storage areas, exterior, and evacuation route gate. Evacuation route gate is obstructed by a heavy spring that renders an unnessisary resistance to opening the gate more than a 20*, LPA is asking the spring to be reinstalled to a position where the door could be opened 90*, or be removed. Administrator adjusted the spring tension.

Fire extinguisher is dated 10-17-25. CO/smoke alarm is functional, water temp is measured at 114.5*F.

LPA interviewed 1 client, 1 clients is out of the facility, 1 client retired for the evening. LPA interviewed 1 staff.

Continued C-Page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CELY'S CARE HOME LLC
FACILITY NUMBER: 392701351
VISIT DATE: 01/28/2026
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Admin files were reviewed, including but not limited to: admin certificate(expiring 5.8.26), LIC 500(Staff schedule has 17 hours of coverage week days, week nights seems to have a 7 hour vacancy from 11pm-6am, staff schedule has 9 hours of coverage on the weekends, weekends seem to have a 15 hour vacancy from 3pm-6am), Aministrator provided there she and her husband are live in monday to friday, 1 additional staff is to be hired, LPA gave guidance night supervision requires on call on premises staff, and staff should have 5 hours of break between shift. LIC 9020(client Roster), Hiv Training, Fire drill record, Emergency preparedness, Infection control Plan, required posters(Personal rights, Ombudsman, facility license, facility sketch), and Plan of Op(control of the property via grant deed, surety bond(no bond) and liability insurance) are up to date and present.

Client files were reviewed, including but not limiting to: recent medical assessments, admission agreements, functional capability assessments, and needs and services plans. Client exhibt restricted conditions: o2 administration due to copd, insulin dependant diabedies, facility does not have these services covered in ammendments toPlan of Op or having adequate trainings(4 hours per) for staff. Lpa gave guidance that more of the yearly training should be devoted to the following topics: wandering, diebetes, 02 administration. Needs and services plans read as the same for folks and are unfilled out in some portions. LPA gave guidance to contextualize needs and services plan to the specific needs of the clients. Admission agreement contains prohibited terms(refund conditions only allow for 15 days of basic services after the death of the resident.) LPA gave guidance that terms meet admission guidlines. LPA is requesting a copy of the updated admission agreement and the needs and services plans 2/5/26.

Staff files were reviewed, including but not limited to: first aid training, continuing education, and criminal background check, health screening. Most annual training records are due for January, some records are out of date by a few days. Staff training is inadequate for restricted condition care, staff should have 4 hours annually for each restricted condition. LPA gave guidance to seek a licensed medical service provider outside her current employ to run an inservice for the restricted condition care for all employees.

no citation was issued, a copy of the report was given. Exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC809 (FAS) - (06/04)
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