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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005072
Report Date: 08/17/2021
Date Signed: 08/18/2021 05:38:27 AM

Document Has Been Signed on 08/18/2021 05:38 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:SONIA'S GUEST HOME 3FACILITY NUMBER:
397005072
ADMINISTRATOR:GAPASIN, SONIAFACILITY TYPE:
740
ADDRESS:2933 ANGEL DRIVETELEPHONE:
(209) 609-9342
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:TIME COMPLETED:
12:10 PM
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On 08/17/21 at 10:35 AM LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Sonia Gapasin of the LPA's visit and Ms. Gapasin arrived during the visit. LPA explained the purpose of the visit and staff 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 is a 6 bed facility with a current census of 6. There are 4 client bedrooms and 3 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 and other signage noted. Medications noted to be locked to residents in care. Lysol, Clorox and other hazardous cleaning supplies were seen in the unlocked cabinet under the sink in two client bathrooms. LPA also conducted the infection control domain tool.

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 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: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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: SONIA'S GUEST HOME 3
FACILITY NUMBER: 397005072
VISIT DATE: 08/17/2021
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The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were checked April 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.

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. Exit interview was held and a report was given to Sonia Gapasin
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2021 05:38 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 08/17/2021 at 11:33 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: SONIA'S GUEST HOME 3
FACILITY NUMBER: 397005072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2021
Plan of Correction
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LPA observed Lysol, Clorox and other cleaning supplies in unlocked cabinets under the client bathroom sinks. Facility secured items while LPA was present. Facility Administrator to provide in-service training of all care staff within two weeks and send proof of training to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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