397002540-1-13-2022-27-AS-BJAS-CAMMDK-20220113083113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002540
Report Date: 01/12/2022
Date Signed: 01/13/2022 08:31:18 AM

Document Has Been Signed on 01/13/2022 08:31 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:	VILLA TERESA MEMORY CARE HOME		FACILITY NUMBER:	397002540
ADMINISTRATOR:	ESTRELLA JOSE		FACILITY TYPE:	740
ADDRESS:	2477 CARPENTER ROAD		TELEPHONE:	(209) 462-4239
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY: 6		CENSUS: 5	DATE:	01/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Allan Jose, Facility Administrator		TIME COMPLETED:	10:35 AM

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	LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Administrator Allan Jose of the LPA's visit. LPA explained the purpose of the visit and Allan accompanied LPA on the facility inspection. LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility with a capacity of 6 and a current census of 5 with 4 client bedrooms and 2 client bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Medications and toxins noted to be locked to residents in care. LPA also conducted the infection control domain tool. The facility common areas were clean and furnished. Smoke and carbon detectors were tested are are operational. Fire extinguishers were serviced in August 2021 and are in compliance. Facility has an emergency food and water supply in a separate storage area in kitchen. All staff on-site have current fingerprint clearances. Water temperature was measured at 128.5 degrees. The required range is 105 to 120 digress F. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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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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: VILLA TERESA MEMORY CARE HOME	FACILITY NUMBER: 397002540
	VISIT DATE: 01/12/2022

NARRATIVE

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The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA requested the following documents to be updated: LIC 500 and LIC 309 as needed.

Per California Code of Regulations, Title 22 one deficiency was observed during this visit for the water temperature Exit interview was held and a report was given to Mr. Jose

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/13/2022 08:31 AM - It Cannot Be Edited

Created By: Bruce Jacobs On 01/12/2022 at 09:59 AM

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: VILLA TERESA MEMORY CARE HOME	FACILITY NUMBER: 397002540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as water temoerature was measured at 127.5 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/21/2022
	Plan of Correction
1 2 3 4	The water gauge was adjustged won as LPA was present, Facility will certified via letter and photos tha the temperature is in the required range of 105 to 120 degrees F.

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:

Liza King

LICENSING EVALUATOR NAME:

Bruce Jacobs

LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC809 (FAS) - (06/04)

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