397004511-12-23-2025-27-AS-NWPN-DPMTUK-20251223140228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004511
Report Date: 12/23/2025
Date Signed: 12/23/2025 02:02:41 PM

Document Has Been Signed on 12/23/2025 02:02 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:	ZOSING CARE HOME		FACILITY NUMBER:	397004511
ADMINISTRATOR/ DIRECTOR:	ANGELICA VELASQUEZ		FACILITY TYPE:	740
ADDRESS:	2777 WISTERIA LANE		TELEPHONE:	(916) 955-1033
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY: 6		CENSUS:	DATE:	12/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Angelica/Gene Velasquez		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived on 12/23/2025 to conduct an annual inspection. LPA met with the administrator Angelica Velasquez and administrator Gene Velasquez to explain the purpose of the visit. Zosing Care Home is a 6 capacity facility for adults aged 60+, there are 0 clients with restricted care, with a total census of 4, 0 ambulatory, 4 nonambulatory, and 0 bedridden. 2 clients on Hospice, 2 clients on home health. Physical Plant was inspected, including but not limited to the kitchen, bedrooms, bathrooms, common areas, storage areas, exteriors, and evacuation routes. Facility is clean, traffic areas are well lit and unobstructed. Kitchen has adequate storage for sharps, toxics, and medication. There is adequate food stored for 4 residents, 2 days of perishable foods, 7 days of non perishable foods. Medication against Mar was checked for 2 clients at random. 1 client's medication is filled out for future dispersals, administrator provided while in a rush to account for the mornings medication dispersal, the staff also filled out the pm dispersal section for 12/23/25. LPA gave guidance for the staff not to rush medication documentation. Bedrooms have required furniture and furnishings, including mattress encasements(rubber hospital type). Bathrooms hardware is functional, water measured at sink at 119.1 *F. Evacuation route gate swings freely, outside is free of obstructions. Continued on C Page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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

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)

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ZOSING CARE HOME	FACILITY NUMBER: 397004511
	VISIT DATE: 12/23/2025

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

Client files were reviewed.

admission agreement has unenforceable terms: Lpa gave guidance the admission agreement is always terminated on the death of the resident. the refund policy and termination policy on basic services should be reviewed and updated by the licensee.

The safeguarded property forms are not filled out for 1 resident, needs and services plan not filled out for 2 residents. Licensee provided that the two residents are new, from within the last two weeks.

602's are up to date. Half rails should be ordered by physician and for repositioning purposes only.

Hospice care plans are up to date, Home health plans are up to date. for one client, Home Heath Care plan says bed bound, Hospice nurse agrees with that estimation saying the client cannot support thier weight. While all the clients 602's reflect nonambulatory status, LPA has concerns related to the one clients ability to reposition themselves, given the 602, home health, and hospice care plans assessments for the resident. The Facility is licensed for 6 non-ambulatory, 2 may be on hospice. a Fire Clearance request for an update the license for expanding the hospice/bedridden allowable was made to LPA Charlie Yang via email 2/5/2025, and the request wasn't put though. LPA is asking the licensee to send in a new request; new facility sketch with the updated staff room and nonambulatory/bedridden room designations update for processing into an new LIC 850. The LPA notes there is a master bedroom with access to the outside world with ample space for 2 bedridden. The physical Plan Of Operation file submitted to licensing containing the original granted fire clearance 850, is unavailable for review. The facility does not have a copy of their most recent fire clearance for review. Given that all residents are declared non-ambulatory, and the facility has physical rooms for meeting needs of the current clients if they were to become bedridden, the immediate action by the licensee to get a new 850, and the unknown quality of the statements on the most recent 850, the LPA is not going to cite fire clearance at this time but schedule a follow up case management for after the fire inspection is completed.

Staff records were reviewed, including a first aid/cpr, additional training and entry training, criminal background clearance and finger printing. Documents are up to date and present.

Administrator files were reviewed, including facility posters, facility sketch, facility license, administrator certificate, and program design, infection control plan, evacuation plan. Documents are up to date and present.

2 residents were interviewed. 1 asleep, 1 nonverbal. 2 staff were interviewed.

No citations issued, a copy of the report was read and given to the administrator. Exit interview.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3