397004082-8-7-2025-27-AS-APAA-DKBPDQ-20250807111354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004082
Report Date: 08/07/2025
Date Signed: 08/07/2025 11:14:22 AM

Document Has Been Signed on 08/07/2025 11:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GAVERO'S CARE HOME		FACILITY NUMBER:	397004082
ADMINISTRATOR/ DIRECTOR:	GAVERO, EDSON JADE		FACILITY TYPE:	740
ADDRESS:	334 REDWOOD AVE		TELEPHONE:	(209) 836-5727
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 6		CENSUS: 6	DATE:	08/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Jesusa Gavero		TIME VISIT/ INSPECTION COMPLETED:	11:30 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	On 08/07/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived to the facility unannounced to conduct an annual visit. LPA was greeted by Facility Designated Representative, Jesusa Gavero and explained the purpose of the visit. There was one other staff members present at the facility, Charles Gavero. It was learned that the Facility Designated Administrator (FDA), was unable to come to the facility at this time. LPA continued the visit with FDR Gavero. This facility is licensed to serve and retain 6 residents who are 60 and over of which may be all non-ambulatory. This facility also holds a dementia plan on file. Current Census was 6. A brief interview with FDR Gavero was conducted. LPA reviewed 6 resident files were reviewed. 6 out of 6 resident files were complete and up to date. LPA reviewed 3 staff files were reviewed. 3 out 3 staff files were complete and up to date. The Facility Designated Administrator has a current administrator certificate #7005301740 and expires on 09/06/2026. A tour of the facility was conducted. There are currently two fire extinguishers located throughout the facility and have been serviced by Coast Fire Equipment on 04/23/2025. Smoke alarms and carbon monoxide detectors were present and in compliance. Last emergency safety drill was conducted with residents on 04/02/2025. The kitchen area was toured. LPA observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components. The exterior of the physical plant was toured with no hazards present. One exit gate was inspected and the perimeter fence was observed to be stable.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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: GAVERO'S CARE HOME	FACILITY NUMBER: 397004082
	VISIT DATE: 08/07/2025

NARRATIVE

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The common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of 4 resident rooms were conducted. Resident furniture was observed to be sufficient to meet resident needs at this time.
A linen closet was located in the hallway and presented a sufficient amount of linen to adequately supply and meet the needs of the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured.
A tour of the garage was conducted. Additional storage for supplies and files were stored in cabinets. Additional perishable food supply was identified.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610e

Based on the observations based during the visit, there are no deficiencies were observed or cited during this annual visit.

An exit interview was conducted and a copy of this report was provided to the Facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC809 (FAS) - (06/04)

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